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December 26, 2006
When a patient takes a medication and has a reaction, the first question the coder should ask is, “Was the medication taken as prescribed?” The answer will determine whether the reaction should be classified as an adverse reaction or a poisoning. Poisoning • drugs given in error (wrong drug); • medication given in error (wrong dose, wrong patient, wrong route of administration); • overdose of a drug given or taken intentionally; • reaction to illegal or illicit drugs (eg, cocaine); • prescription or nonprescription medication taken with alcohol; or • combination of a prescribed drug taken with a nonprescribed drug even if drugs were taken correctly. Therefore, in a poisoning, something was done wrong. For coding purposes, the code for the drug that caused the poisoning is listed first. These codes are located in the first column in the Table of Drugs and Chemicals. If more than one drug is involved, you will need to select a poisoning code for each drug. An E code from one of the other columns should be selected to identify the circumstances surrounding the poisoning. It should be noted that an E code from the column labeled “Therapeutic Use” is never used with the code from the first column labeled “Poisoning.” The manifestation of the poisoning, such as coma or respiratory failure, is listed as a secondary diagnosis (ICD-9-CM Official Guidelines for Coding and Reporting, effective November 15, 2006, pages 52-53). Excessive or binge drinking that causes alcohol poisoning is assigned to code 980.0, Toxic effect of ethyl alcohol; E860.0, Accidental poisoning by alcoholic beverages; and 305.00, Alcohol abuse. For coding purposes, a poisoning occurs when too much of a medication has been taken, not when the patient takes too little of a medication. If there has been a reduction in the patient’s dosage and the patient has a recurrence of the condition due to the reduction of the medication, then the medical condition is sequenced as the principal diagnosis. Assign code V15.81 as a secondary diagnosis to show that it was the patient’s decision to decrease the dosage (AHA Coding Clinic for ICD-9-CM, 1999, second quarter, pages 17-18). If there is no mention of the drug having been taken incorrectly, it is assumed that the drug reaction is an adverse reaction. Adverse Reaction • the build-up or accumulation of a drug in the body (toxicity); • hypersensitivity or allergic reaction to a drug; • the combined effects of taking one or more prescribed drugs (Drugs may be prescribed by one or more physicians.); • a patient’s unexpected reaction to a drug (includes over-the-counter medications taken according to packaging instructions); and • the side effects of a drug which may occur in some patients. Therefore, the patient experienced a reaction even though it was the correct patient, drug, dose, and route of administration. When a patient suffers an adverse effect from a drug, the adverse effect will manifest itself in a physical disorder or condition. According to coding guidelines, the documented manifestation is sequenced first. An E code is used to identify the drug involved from the column labeled “Therapeutic Use” in the Table of Drugs and Chemicals. The E code is sequenced after the manifestation. The E codes in this column are used only when a patient has an adverse reaction to a drug, which was taken or given properly. It is mandatory to assign an E code with adverse reactions. If the manifestation is not documented in the medical record, the physician should be queried for clarification. However, if no further documentation is available, then code 796.0, Nonspecific abnormal toxicological finding, is assigned in the inpatient setting (AHA Coding Clinic for ICD-9-CM, 1997, first quarter, page 16). Code 995.2, Unspecified adverse effect of drug, should not be used in the inpatient setting and should only be used in rare circumstances in the outpatient setting (AHA Coding Clinic for ICD-9-CM, 1997, second quarter, page 12). Coding and sequencing for poisoning or adverse reactions are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding. — This information was prepared by Audrey
Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a
business of 3M Health Information Systems, a supplier of coding and
classification systems to nearly 5,000 healthcare providers. The company
and its representatives do not assume any responsibility for reimbursement
decisions or claims denials made by providers or payers as the result
of the misuse of this coding information. More information about 3M
Health Information Systems is available at www.3mhis.com
or by calling 800-367-2447
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