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Monthly CDI Scenario Discussion – September 2019

Topic:  Altered Mental Status, Dementia with Encephalopathy


  • 85 y/o female admitted with Sepsis secondary to UTI and altered mental status.
  • History of dementia. Decreased responsiveness noted by patient’s sister who reports this is significantly different than her usual state.
  • H/P: “Patient is disoriented, confused with decreased responsiveness, hard to arouse. The degree at onset was severe.  Pt. is bedbound 2/2 to her dementia and general debility. Chronic foley.”
  • Treatment/evaluation: CT brain, IVF, change foley catheter, IV antibiotics, daily labs, neuro checks q 2h, turn schedule, psych consult.
  • CT of brain shows diffuse microvascular chronic changes; no acute intracranial abnormalities.
  • Progress note on hospital day three “Patient is back to baseline mental status.”
  • Discharge summary on hospital day five notes, “Altered mental status secondary to UTI/Sepsis with underlying dementia. Patient is back to baseline.”
  • Patient discharged to skilled nursing facility.

Question:   Are there any query opportunities based on the scenario stated above?


Patient presents with indicators of acute encephalopathy based on the information provided.

  • Acute Encephalopathy is characterized by alteration in brain function due to a systemic underlying cause usually resulting in altered mental status.
  • Acute Encephalopathy is reversible and resolves when the underlying cause is corrected.
  • Acute Encephalopathy does not involve structural brain changes on CT of brain.
  • Acute Encephalopathy is noted as an acute or sub-acute mental status alteration associated with metabolic or toxic factors that improves or returns to baseline status when the causative factors are corrected.
  • Improvement = probable encephalopathy No improvement = less likely encephalopathy

UASI Recommends:

  • Query for Encephalopathy: Specificity is important, unspecified encephalopathy is a CC whereas documentation of specificity (Metabolic) would add an MCC.
  • Query for linkage between UTI and Chronic Foley.

Documentation without clarification:

Principal diagnosis:     A419 Sepsis unspecified organism

Secondary diagnosis:  F0390 Unspecified Dementia without behavioral disturbance

                                    N39.0 Urinary Tract Infection

DRG 872 w/o MCC RW=1.0529, GMLOS= 3.7, SOI/ROM 2/2

Documentation with clarification:

Principal Diagnosis: T83.511A Infection and inflammatory reaction due to indwelling catheter

Secondary diagnosis: G93.41 Metabolic Encephalopathy

                                    A41.9 Sepsis unspecified organism

F0390 Unspecified Dementia without behavioral disturbance

                                    N39.0 Urinary Tract Infection

DRG 698 Other Kidney and Urinary Tract Diagnosis with MCC RW=1.6151, GMLOS=4.9, SOI/ROM 3/3

 CDI Educational Tips:

  • Altered Mental Status is considered a symptom and should be clarified.
  • Clarify if there is a causal relationship between chronic indwelling Foley catheter and UTI.
  • Encephalopathy can be either acute (functional) or chronic (structural).
  • Baseline status is important for the clinical validation of several diagnoses, including encephalopathy.
  • The underlying cause of dementia should be identified whenever possible.
  • When a significant alteration of mental status has occurred and systemic toxic or metabolic factors are present, it is a rather simple matter to diagnose toxic or metabolic encephalopathy when mental status returns to baseline as these abnormalities are corrected.
  • Encephalopathy greatly impacts severity of illness/risk of mortality.

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.