Deciphering Documentation and Coding Dilemmas for Altered Mental Status

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Deciphering Documentation and Coding Dilemmas for Altered Mental Status

Product Code: YHHA040617

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Deciphering Documentation and Coding Dilemmas for Altered Mental Status

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Presented on:
Thursday, April 6, 2017
1:00-2:30 p.m. Eastern

Presented by:
Richard D. Pinson, MD, FACP, CCS
Cynthia L. Tang, RHIA, CCS


Level of Program:

Join expert speakers Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS, as they decipher common clinical and coding dilemmas associated with altered mental status through real case examples.

Altered mental status is an ambiguous symptom within ICD-10-CM. The role of the CDI specialist is to equate it with a more definitive diagnosis that better represents the mental status and/or level of consciousness of the patient and accurately captures the associated severity of illness.

CDI specialists need to review the health record for clinical indicators that suggest a definitive diagnosis of which altered mental status is a symptom. Because there are several pathways to obtaining such a diagnosis, CDI professionals must consider the most common differential diagnoses, which requires knowledge of the patient’s baseline mental status, including substance use status, the presence or absence of infection, and/or the presence or absence of trauma. Additionally, if a patient with altered mental status has a history of dementia or other psychiatric condition, the CDI specialist should review the record to determine whether this is the patient’s baseline mental status or a change. 

At the conclusion of this program, participants will be able to: 

  • Identify etiology and potential complications associated with altered mental status
  • Differentiate between altered level of consciousness and encephalopathy
  • Incorporate clinical criteria into existing processes
  • Explain key coding and quality documentation requirements associated with altered mental status
  • Compose effective queries related to new definitions
  • Describe recommendations for psychiatric patients and dementia patients

Who Should Listen? 

  • CDI specialists
  • CDI managers/directors
  • HIM managers/directors
  • Inpatient coders
  • Physician advisors
  • Hospital quality staff


  • Altered mental status clinical factors
    • Altered level of consciousness
      • Definition
      • Etiology
      • Complications
    • Encephalopathy
      • Definition
      • Types
      • Etiology
      • Complications
  • Coding
    • Correct principal diagnoses
    • Complications
    • ICD-10 impact
    • Coding nuances, especially coma
    • Additional coding challenges
    • Psychiatric coding issues
  • Documentation
    • Correct documentation
    • Additional documentation challenges
      • Dementia patients
      • Psychiatric patients
  • Case examples
    • Distinguishing encephalopathy on top of dementia
  • Q&A

Meet the Speakers 

Richard D. Pinson, MD, FACP, CCS, of Chattanooga, Tennessee, has expertise in improving coding and clinical documentation, managing clinical resources, developing clinical practice guidelines, and using data to transform physician practice patterns and behaviors. He is a physician consultant and a former assistant professor of clinical medicine at Vanderbilt University in Nashville. He is the author, with Cynthia Tang, of the popular CDI Pocket Guide.

Cynthia L. Tang, RHIA, CCS, of Houston, is an expert in health information management, coding, and clinical resource management. She has more than 20 years consulting experience in redesigning operations to promote hospital financial health, improve clinical documentation, optimize reimbursement and compliance, and identify areas to improve care management and cost efficiency. She is the author, with Dr. Richard Pinson, of the popular CDI Pocket Guide.

Continuing Education

American Nurses Credentialing Center (ANCC)
(Nursing contact hours valid for live webcast participant only) - HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This educational activity for 1.5 nursing contact hours is provided by HCPro. (Ability to claim nursing contact hours for this webinar expires on: 04/03/2018)

Association of Clinical Documentation Improvement Specialists (ACDIS/CCDS)
(Live + On Demand) - This program has been approved for 1.5 continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification, offered as a service of the Association of Clinical Documentation Improvement Specialists (ACDIS). (Ability to claim CEU’s for this webinar expires on: 04/03/2018)

Webinar system requirements and program materials: 

To fully benefit from the webcast experience, please note you will need a computer equipped with the following: 

Browser: Microsoft Internet Explorer 6 or later, Firefox, Chrome, or Safari, with JavaScript enabled 
Internet: 56K or faster Internet connection (high-speed connection recommended) 
Streaming: for audio/video streaming, Adobe Flash plug-in or Safari browser on iOS devices 

Prior to the webinar, you will receive an email with detailed system requirements, your login information, presentation slides, and other materials that you can print and distribute to all attendees at your location. 

No problem. The On-Demand version is now available. Use it as a training tool at your convenience—whenever your new or existing staff need a refresher or need to understand a new concept. Play it once or dozens of times. A $259 value! 

Participation in the webinar is just $259 per site. All materials must be retrieved from the Internet. 

Call your customer service representative toll-free 800-650-6787 or email if you have questions.