Q&A: Coding for acute mental status change secondary to an infectious process

Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I’m trying to code two different cases in which a physician documents acute mental status change secondary to an infectious process. In each case, the patient’s metabolic panels don’t appear to be abnormal; however, one of the patients is septic. The physician thinks that documenting and coding sepsis separately from encephalopathy would result in unbundling. However, I disagree because coding the sepsis separately demonstrates severity. What is the correct logic to use in each of these cases?

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