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February 2019

Altered Mental Status: More Info Please
By Sarah Elkins
For The Record
Vol. 31 No. 2 P. 10

Use of this generic term in clinical documentation often leads to misrepresentation of the care being provided.

Altered mental status is a phrase commonly uttered among clinicians to characterize a broad spectrum of behaviors and states of being that range from confusion to coma. Generally speaking, the term is just fine when a physician is, well, generally speaking. However, use of the term becomes problematic when it makes its way from clinical conversation into clinical documentation.

When clinical documentation improvement (CDI) experts discover altered mental status is being used as a diagnosis within the chart, they know two things: The documenting physician is undervaluing the care he or she is delivering, and a little education is in order.

Unfortunately, physicians are finding more occasion to document altered mental status due to the rise in Alzheimer’s disease as well as the opioid epidemic. As a result, they’re recognizing the generic term doesn’t cut it.

Why Physicians Use Altered Mental Status
Altered mental status is a phrase all medical students learn early in their education to describe patients who are in some way confused or exhibiting limited consciousness.

“It’s considered a much more professional way to describe someone who is flipped out,” says Victor Freeman, MD, MPP, an adjunct assistant professor in the HIM graduate department at the University of Maryland and national medical director for CDI for Nuance Communications. “The problem is it was always a general descriptor and never provided any additional information about why they were having an altered mental status.”

Indeed, physicians are using what they know to be a widely agreed-upon phrase when they note their patients’ altered mental status. “You read the [term] in high-impact journals like the New England Journal of Medicine and the Annals of Internal Medicine,” says James Kennedy, MD, CCS, CDIP, CCDS, founder and president of CDIMD, a physician consulting firm.

As a result, physicians who use the terminology that they were taught in medical school and that appears in esteemed industry journals have good reason to believe they are accurately documenting a patient’s mental state.

But many practitioners fail to realize that the language they deem commonplace does not always translate to an ICD-10 code. “The physician uses clinical language. The coder is extracting language to produce codes, and there is a great big disconnect between those worlds,” explains Timothy Brundage, MD, CCDS, medical director of The Brundage Group.

The greatest disconnect may be in that physicians are rarely, if ever, offered the opportunity to learn how to properly document or why it’s even important.

“Most residents have never had any education on how to document from anyone other than their attending physicians. Their attending physicians taught them the clinical aspects of documentation, but no one taught them the coding aspects of documentation,” Brundage says.

Since passage of the Affordable Care Act and the subsequent push toward value-based care, it has become incumbent upon physicians to not only deliver quality care but also communicate that level of care to Medicare.

“Generally, even if a physician is doing a bad job of documentation, they’re still treating the patient. Their big frustration with clinical documentation improvement is they’re saying, ‘Are you saying I’m doing a bad job?’ The answer to that is, ‘No, we’re simply saying that your documentation doesn’t reflect how good of a job you’re doing,’” Freeman says.

Once physicians understand their documentation is the only means of illustrating their value, they’re usually on board and open to learning new CDI tools. That makes the hospital happy, too, because reimbursements improve as documentation and coding become more specific. That’s where professionals such as Freeman, Kennedy, and Brundage come in. The hospitals are worried about reimbursements; the physicians are worried about quality measures. CDI is the path that leads to improved outcomes for everyone.

The Perils of Using Altered Mental Status
A coder is tasked with gleaning a complete story for each patient chart. That means capturing the severity of illness and risk of mortality. Yet, altered mental status, for all of its colloquial value among clinicians, carries no value when it comes to risk models.

“The predicament with altered mental status is that it’s so generic. There are words that are much more specific that would better define what the alteration is or what the level of consciousness may be,” Kennedy says.

In September 2018, Freeman presented “A New Framework for Documenting Altered Mental Status” at the AHIMA annual conference. In his presentation, he explained how the vague term fails to communicate what behavior a physician is seeing or the underlying cause of the behavior. The good news, according to Freeman, is that ICD-10 is replete with more appropriate terms that enable a physician to capture exactly how sick a patient is.

Perhaps exacerbating the confusion around the use of altered mental status is the fact that there is a code for it. “R41.82, which is altered mental state, unspecified,” Kennedy says. “While that is codable, more often than not, that code does not affect any risk models that we’re held accountable for.”

The Problem With Definitions
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, which uses the term delirium to describe altered mental status, falls short in providing definitions related to altered mental states caused by underlying physiological conditions. This makes sense given psychiatry’s chief focus on behavior. Unfortunately, ICD-10 is no more helpful to the physician seeking improved clinical documentation.

“One of the problems with ICD-10 is that it does not provide definitions,” Kennedy says. “It is, in essence, a dictionary without definitions, a telephone book.”

So, what’s a physician to do? According to Kennedy, “It is HIM professionals’ responsibility, in my mind, to negotiate with their medical staff what the definitions of all these words are and come to an agreement on it. That way, if the physician is inconsistent, incomplete, imprecise, or conflicting, then the coder can have a conversation with the physician.”

Because leaving documentation open for interpretation is too risky, developing open negotiation and communication between coding staff and physicians is particularly important.

“The coder’s hands are tied,” Freeman says. “They cannot simply interpret what they think a physician meant to say. If they do that, they risk being accused of upcoding. That would be fraud and they could go to jail. So, it is now incumbent on all physicians to learn their part in making this system work.”

Capturing the Complete Picture
The first step in accurately documenting what one might generally call altered mental status is to identify the behavioral presentation, for which, Freeman discovered, there are many different codes in existence, for example, delirium, intoxication, psychosis, lethargy, stupor, and coma.

“All of these are codable terms,” Freeman says, adding that there are many other less common presentations. “Now, because I’ve told you what it looked like, that doesn’t tell you what’s going on behind the scenes. And, it turns out within the coding system, there are different types of physiological causes for what happened in your brain. And that fancy term is encephalopathy.”

Depending on what other issues are occurring in the body, the encephalopathy will be specific. For example, a complication of diabetes might be metabolic encephalopathy. Or, if the patient has an overdose of a prescription drug, toxic encephalopathy may be the correct notation.

Brundage elaborates, “Diagnoses carry higher weight in the coding system and they show patients who are, you could say, more ill on paper. So, altered mental status is a symptom, but metabolic encephalopathy is a diagnosis. If a symptom is caused by a medical diagnosis such as hyponatremia, hypoglycemia, something of that nature, the symptom plus the cause is what allows the doctor to diagnose metabolic encephalopathy. If that diagnosis is placed in the medical record, it will show a patient who is more ill, and if it is captured present on admission, it will go into Medicare’s calculated risk of mortality.”

A Case in Point
Recently, Brundage was asked to review the clinical documentation of a physician in Florida. The doctor had documented that his patient had a urinary tract infection, hypotension, acute kidney injury, altered mental status, and metabolic encephalopathy. However, he fell short of connecting the dots to present a complete picture of his patient’s severity of illness.

According to Brundage, altered mental status should have been used to support a diagnosis of severe sepsis or septic shock. Additionally, hypotension supports a diagnosis of shock.

“Now you’ve got a patient that the doctor admitted to the hospital with a urinary tract infection, acute kidney injury, and metabolic encephalopathy, which you would think sounds like a patient who is pretty sick, but the reality is the patient had a urinary tract infection causing the acute kidney injury, causing the metabolic encephalopathy, and if you link those together, you’re able to diagnose sepsis. When sepsis causes organ dysfunction, that actually pushes it into the category of severe sepsis which has a higher risk of mortality,” Brundage says.

The lesson learned in this case is that the physician, despite delivering excellent care, had not adequately communicated how sick his patient was. “He’s not getting credit for what he’s done. If that patient passes away, it will appear as if the patient passed away from a urinary tract infection when the reality is the patient passed away from septic shock and he missed the diagnosis,” Brundage says.

Such scenarios are why CDI professionals have become essential to hospital operations. Freeman says physicians often have no idea they’re being evaluated in this way. He broaches the subject with his more skeptical audiences by explaining, “This is about your performance profile.”

By understanding what the clinical documentation is demanding of them, physicians are better able to take control of their quality measures. “If I can show that my patient is really sick, the patient has a longer expected length of stay. I have gone from keeping them in the hospital for too long to getting them out earlier than expected,” Freeman says.

“Physicians don’t want to be seen as a low quality of doctor. The truth of the matter is, if you talk to them using ‘quality language,’ they never get upset,” Brundage says.

Glasgow Coma Scale
Developed in the 1970s to score a patient’s level of consciousness, the Glasgow Coma Scale is a valuable yet woefully underused tool in objectively identifying a patient’s specific mental status. For Freeman, the scale’s beauty is in that it can measure a patient over time to assess an improving or worsening condition.

“The biggest problem is nobody wants to use it. It’s most often used by neurologists or critical care physicians, and even then it’s often not used over a period of time,” he says.

Kennedy adds, “It’s very beneficial because, unlike most diagnoses in ICD-10, codes for Glasgow Coma Scale can be taken from nursing documentation. It does not require a physician to actually document the scale. We can get it from nursing or even EMT documentation.”

Best of all, “the Glasgow Coma Scale affects all of the risk model,” whereas other behavioral presentations may not, he adds.

Using whatever tools translate best to coding, CDI specialists strive to have physicians tell the most complete story possible for the benefit of the patient, the physicians themselves, and the health care organization.

“That’s what we want them to do. We want them to diagnose coma. We want them to diagnose metabolic encephalopathy. We want them to diagnose severe sepsis. We want them to diagnose shock,” Brundage says.

Everyone Wins
Improving the clinical documentation of various mental statuses isn’t only a matter of a physician’s performance profile. “It’s also about their physician group, their specialty department, and their medical staff’s reputation as a whole,” Freeman says.

To put it another way, Kennedy says, “There is a way of communicating that enhances the shared vision of the physician and the hospital, that together they can do better than separately.”

However, it’s important to note physicians aren’t likely to make clinical documentation improvements on their own. As Freeman, Brundage, and Kennedy have witnessed firsthand, many physicians don’t realize how their documentation affects risk models.

As a result, physician advisors are taking a leading role in CDI efforts, Brundage says. “Hospitals are having a tough time if they don’t have a physician in this space helping them with their revenue cycle and value-based purchasing,” he notes.

In the end, the goal is to document altered mental status in a manner that best represents the quality of care being given.

— Sarah Elkins is a freelance writer based in West Virginia.