‘Raising code will better recognize impact of delirium when determining severity of illness’
ACLP is lobbying to upgrade diagnosis-related group coding for delirium.
Meeting a deadline of June 28, the Academy has written to the Centers for Medicare and Medicaid Services (CMS) to request the assignment of major complication or comorbidity to the diagnosis of delirium due to a known physiological condition—putting it on an equal footing with metabolic encephalopathy.
Co-signatories along with ACLP to the CMS letter are The Association of Medicine and Psychiatry and the American Delirium Society.
“The recommended change will better recognize the importance of delirium in determining illness severity and complexity in the hospitalized patient [bringing it] into alignment with metabolic encephalopathy,” says Board director Thomas Heinrich, MD, FACLP.
‘Delirium’ is either used synonymously with encephalopathy or, in the most reductionist definition of delirium, considered an agitated or hyperactive subtype of encephalopathy.
Dr. Heinrich has been leading the Academy’s case for the coding change. He introduced a colleague from the Medical College of Wisconsin to present scientific evidence demonstrating the potential impact of the re-coding to ACLP’s Executive Committee.
In the recommendation to the CMS, Dr. Heinrich says: “Whether considered a severe subtype of encephalopathy or synonymous with encephalopathy, delirium has the potential to cause significant adverse outcomes in hospitalized patients suffering from this complex and dangerous disorder.”
The National Institute of Neurologic Disorders and Stroke describes encephalopathy as altered brain function or structure. It presents with an altered mental state that may cause a progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, and alteration of consciousness. In other words, its hallmark clinical phenotype is delirium.
“The definition of delirium is essentially equivalent to that of encephalopathy,” says Dr. Heinrich. It “describes an impairment in brain function leading to an altered mental status due to an underlying toxic, metabolic, or neurologic insult. The signs and symptoms of delirium include an acute disturbance in attention and awareness, change in cognition, altered level arousal, and typically an acute fluctuating clinical course.
“Clinicians and researchers have used many terms to describe delirium historically,” he says, “such as toxic/metabolic encephalopathy, intensive care unit (ICU) psychosis, acute confusion, and acute brain failure.”
In 1987, the American Psychiatric Association (APA) provided diagnostic criteria for delirium in its third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). The criteria have been further refined with subsequent editions of the DSM leading up to the current DSM-5 in 2013, which specifies that delirium is a “direct physiological consequence” of a medical condition, substance intoxication or withdrawal, toxin exposure, or multiple etiologies.
“The DSM criteria have become the most widely accepted clinical and research standards to diagnose patients suffering from delirium,” says Dr. Heinrich.
Delirium is linked to increased mortality across multiple patient populations. Patients who develop delirium in the ICU have a two-to-four-times increased risk of death when compared to a matched patient population who do not develop delirium.
Patients who experience delirium on a general medicine unit have one-and-a-half-times the increased risk for death in the year following hospitalization. Delirious patients in the emergency department have an approximately 70% increased risk of death during the first six months following the visit.
Delirium has also been associated with an impairment in physical function for 30 days or more after discharge, and has been linked to new cognitive impairment in previously healthy individuals a year after their ICU admission and occurrence of delirium. Cognitive impairment was significant, with more than 30% showing deficits similar to patients with a mild traumatic brain injury.
In patients with prior cognitive impairment, such as Alzheimer’s disease, the pre-existing dementia is worsened by an episode of delirium. In the critically ill patient, delirium is associated with more medical complications, longer duration of mechanical ventilation, higher rates of discharge to skilled nursing facilities, and longer length of stay (LOS) in ICU and hospital when compared to critically ill patients who were not delirious.
Further, “unlike encephalopathy, delirium has well-validated diagnostic criteria that have allowed for the characterization of its complexity and numerous adverse outcomes.
“Indeed, the robust literature detailing the impact of delirium on patient and caregiver distress, care complexity and costs, readmissions, rates of functional decline, institutionalization, cognitive decline, subsequent dementia diagnosis, and mortality simply has no parallel in the encephalopathy literature.”
Based on this referenced data, ACLP has urged the CMS to consider this change: “We firmly believe and submit that this diagnosis of delirium meets the MCC-qualifying threshold of clinical severity and complexity and deserves recognition as such.”
However, if toxic encephalopathy (due to fluoroquinolones), a major comorbidity under the current rating system, were added as a diagnosis, the LOS would increase to 4.1, and would be reflected positively in the reimbursement.
Dr. Heinrich points out two important points from this example:
The CMS has been reviewing code rates and inviting comments for policy changes for its fiscal year 2022.
Dr. Heinrich told the Executive Committee: “This is a meaningful way we can provide value to our members. It will help our members demonstrate value to their respective organizations. It is also the right thing from a fairness standpoint as it gets Psychiatry and Neurology to an equal level for treating the same illness.”