prepared by amy brazell, rhit, ccs, cpc-h 1 drug toxicity poisoning vs. adverse effect
TRANSCRIPT
Prepared by Amy Brazell, RHIT, CCS, CPC-H
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Drug Toxicity
Poisoning
Vs.
Adverse Effect
Prepared by Amy Brazell, RHIT, CCS, CPC-H
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Introduction• Drug toxicity is very
common – 35% of original Star Trek episodes included toxin related events
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EPA Definition of Toxicity• The degree to which a
chemical substance elicits a deleterious or adverse effect upon the biological system of an organism exposed to the substance over a designated period of time
• Leading toxins: analgesics, antidepressants, cardiovascular drugs, stimulants, “street” drugs
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EPA definition of Adverse Effect• Any harmful effect to
plants and animals due to exposure to a substance (i.e. a chemical contaminant). The effect is something that causes harm to the normal functioning of the plant or animal.
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Reason for Coding Confusion:• Index under Toxicity:
– Drug• Asymptomatic - 796.0• Symptomatic - See Table of Drugs and
chemicals
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Symptomatic is not necessarily poisoning
• See the Notes at the beginning of the Table – many coders ignore this information
• Poisoning is assigned when – Error was made in drug prescription– Overdose of a drug intentionally or unintentionally
taken– A non-prescribed drug taken with correctly prescribed
and properly administered drug
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Using the Table
• If the drug you are looking up is not in the Table you will need to find an alternate description of the drug.
• Ex. Xanax = benzodiazepine– Tylenol = acetaminophen– Paxil = antidepressant
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E codes for Drugs• Accidental Poisoning
E850-E869• Therapeutic Use
E930-E949• Suicide Attempt
E950-E952• Assault E961-E962• Undetermined
E980-E982
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Homicides by Poisoning• 2005: 85 homicidal
poisonings• ICD10: X85- X90
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Coding Adverse Effects
• Conditions due to drugs are classified as adverse effects when the correct substance was administered as prescribed.
• Conditions due to the interaction of 2 or more prescribed drugs, each used correctly, is classified as an adverse effect.
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Drug Interactions
• A condition which is the result of an interaction of a drug used correctly with a non-prescribed drug or with alcohol is classified as poisoning.
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Contribution of Drug Interactions to Preventable ADRs
• Drug interactions represent 3-5% of preventable in-hospital ADRs
• Drug interactions are an important contributor to number of ED visits and hospital admissions
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Sequencing of Codes
• The code for an adverse effect is sequenced first, followed by an E code indicating the responsible drug or drugs.
• For poisoning, the poisoning code is sequenced first, followed by a code for the manifestation and an E code for the circumstance of the poisoning.
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Poisoning Coding Example
• Coma due to valium taken as prescribed but with two martinis:
• 980.0 - Poisoning due to alcohol
• 969.4 - Poisoning due to Valium
• 780.01 - Coma
• E860.0 - Accidental Poisoning by alcohol
• E853.2 - Accidental Poisoning by Valium
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Substance abuse
• An acute condition due to alcohol or drugs involved in abuse is classified as poisoning.
• A chronic condition related to drug or alcohol abuse is not classified as poisoning. Ex. Alcoholic cirrhosis – 571.2
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Unspecified Adverse Effect of Drug
• Codes 995.20 - 995.29 - Effective 10/1/06• 995.20 Unspecified adverse effect of
unspecified drug, medicinal, and biological substance
• 995.22 Unspecified adverse effect of anesthesia
• 995.23 Unspecified adverse effect of insulin• 995.27 Other drug allergy• 995.29 Unspecified adverse effect of other
drug, medicinal and biological substance
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995.20 – 995.29• These codes should not be used in the inpatient
setting.
• In the outpatient setting they should only be used where no sign or symptom is documented.
• An additional code from the E930 through E949 series is also assigned to indicate the responsible drug or biological substance.
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Late Effects
• For adverse effects, a code is assigned for the residual condition followed by code 909.5, Late effect of adverse effect of drug, followed by an E code for the drug.
• If the drug is still being taken then the adverse effect is coded as current even if it is a chronic condition. Ex. 251.8 and E932.0 for steroid induced diabetes
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Late Effects (cont.)
• For poisoning late effects, the residual condition is coded first, followed by 909.0, Late effect of poisoning due to drug, followed by E929.2, Late effects of poisoning.
• There are no late effect E codes for adverse reactions.
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JAKE LEG
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Coding Jake Leg• The preacher – took as directed:
– Code for Jake leg– E947.8 – adverse effect
Aunt Dinah – she took too much:
977.8 – poisoning
Code for Jake leg
E858.8 – accidental poisoning
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Coding Jake Leg
• The singer: Wasn’t taking Jake for therapeutic purposes
• 977.8
• Code for jake leg
• E858.8
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Coding Jake Leg- The Twist• But….• It wasn’t Jake which
caused Jake leg• It was an adulterant
that was added to Jake
• Poisoning – 989.89, Code for Jake leg, E868.8
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Late Effect- Jake leg
• If it didn’t kill the person then the person was left with permanent effects.
• So what is the code for Jake leg?
• ICD9 index:
• Neuropathy, Jamaican (ginger) : 357.7
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Coding adverse effects is important
• Over 2 million serious ADRs yearly
• Nursing home patients ADR rate 350,000 yearly
• Unintentional drug poisoning increased from 12,186 in 1999 to 20,950 in 2004
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ICD10
• Unintentional Poisoning deaths: – Codes X45-X49– The greatest increase was among the “other
and unspecified” drugs, psychotherapeutic drugs, and narcotic and hallucinagen drugs.
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Costs Associated with ADRs
• $136 billion yearly
• Greater than total costs of cardiovascular or diabetic care
• ADRs cause 1 out of 5 injuries or deaths per year to hospitalized patients
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Why are there so many ADRs?
• Two-thirds of patient visits result in a prescription
• 2.8 Billion outpatient prescriptions (10 per person in the U.S.) filled in 2000
• ADRs increase exponentially with 4 or more medications
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Many reasons for ADRs
• Drug-disease interactions– Liver disease– Renal disease– Cardiac disease – Acute viral infection– Hypothyroidism or hyperthyroidism
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Other reasons
• Drug-food interactions– Tetracycline and milk products– Warfarin and vitamin K containing foods– Grapefruit juice
Quiz- name a vitamin K containing food
Name a drug or type of drug you shouldn’t take with grapefruit
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Coding examples of ADRs:
• Epistaxis due to Coumadin: 784.7, E934.2
• Dementia due to lithium toxicity: 292.82, E939.8
• Both of these examples assume the patient is taking the medication as prescribed
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Coding Challenge:• A 26 yo. man has testicular cancer with
metastasis to the lungs. He has no hx of CAD and is not taking any medications. No drug or alcohol abuse. Smoker for 9 yrs.
• He has no significant adverse effects after his first course of chemotherapy with cisplatin, belomycin, and etoposide. On day 8, he received another dose of bleomycin without any adverse effect.
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Coding Challenge, cont.
• 36 hours later he presents to the ED with severe chest pain, shortness of breath and diaphoresis. The ECG showed an acute inferior wall MI. A cardiac catherization showed complete occlusion of the right coronary artery
• Final diagnosis: bleomycin-induced MI
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Second challenge:
• Torsades de Pointes occurring in association with Terfenadine Use– 39 yo. female with 2-day hx of intermittent
syncope– Rx with terfenadine 60 mg bid and cefaclor
(Ceclor – a cephalosporin) 250 mg tid x 10 d– Self-medicated with ketoconazole (Nizoral)
200 mg bid for vaginal candidiasis– Palpitations, syncope, torsades de pointes
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Real case challenge:
• 29 yo. patient is admitted with aspergillosis of the brain
• Develops ARF and hypokalemia due to nephrotoxicity from the treatment for it, Amphotericin B
• Codes:
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Misconceptions about ADR reporting
• All serious ADRs are documented by the time a drug is marketed
• It is difficult to determine if a drug is responsible
• ADRs should only be reported if absolutely certain
• One reported case can’t make a difference
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Contest
• Name some drugs that have been taken off the market
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Final Coding Challenges
• Sequencing for a patient admitted to ICU for an overdose of Tylenol due to suicidal intentions. Conditions due to the Tylenol include acute liver failure, hepato-renal syndrome, and respiratory failure
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Second Final Coding Challenge
• Patient is admitted to the psychiatric unit for Major Depression following a brief stay in an acute hospital for a suicidal overdose of Xanax which caused electrolyte abnormalities. The patient’s electrolytes are still slightly abnormal and continue to be monitored.
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Third and Fourth Final Challenges
• A patient is admitted to ICU for hallucinations which are determined to be due to an adverse drug reaction
• A patient is admitted to psychiatry for hallucinations which are determined to be due to drug interactions
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Quote:
• “Sir, if you were my husband, I would poison your drink” Lady Aster to Winston Churchill
• “Madam, if I were your husband I would drink it!” – his reply
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References• ICD-9-CM Official Coding Guidelines
– http://www.cdc.gov/nchs/data/icd9/icdguide.pdf.
• AMA Coding Clinics– 95:4Q:34-37– 97:2Q:9-10– 98:4Q:50-51– 90:2Q:11– 04:3Q:8– 09:4Q:80, 111, 113
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References
• AMA Coding Clinics– 95:3Q:10-11– 96:3Q:16– 95:3Q:13– 95:4Q:51– 89:2Q:11– 84:N-D:14-15– 94:5th:6-7
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References• AHA Coding Clinics
– 85:N-D:13– 97:2Q:12, 9-10– 96:2Q:12– 94:4Q:48– 92:3Q:16– 04:3Q:7– 99:2Q:17-18– 07:3Q: 7-8
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References
• http://www.fda.gov/fdac/features/2002/chrtWithdrawals.html
• http://www.fda.gov/cder/biologics/recalls.htm
• http://www.fda.gov/cder/reports/rtn/2002/rtn2002-3.HTM
• http://www.drug-warnings.com/
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References• http://master.emedicine.com/email/ecg/ec
g21answer.html• http://www.fda.gov/cder/drug/drugreaction
s/default.htm• Faye Brown’s ICD-9-CM Coding
Handbook, 2003, 337-338, 342-343• http://www.anaes-icu-waikato.org.nz/ICU/d
ownloads/c96b85uf.ppt
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References
• http://www.cpsc.gov/neiss/completemanual.pdf = National Electronic Injury Surveillance System of the Consumer Product Safety Commission
• CodeWrite Community News June 2004, from the Coding CoP within the American Health Information Management Association