Health Information Management

ICD-10-CM adds a new concept with underdosing

HIM-HIPAA Insider, May 18, 2015

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A patient comes into the ED complaining of blurred vision, headache, dizziness, and numbness in her arms. The patient tells the physician she is currently taking prednisone for her arthritis. The physician determines the prednisone caused her symptoms.

 
Did the patient suffer from prednisone poisoning or an adverse effect of the medication?
 
The main detail to look for is whether the patient took the medication as prescribed, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts.
 
An adverse effect can occur when a therapeutic or diagnostic medication is prescribed correctly and administered properly, but the patient suffers a physical reaction. "When we say prescribed, it doesn't have to be a prescription medication," McCall says. "It could be something over the counter taken as directed on the package."
 
Continue reading "Distinguish between code poisonings, adverse effects to code correctly in ICD-10-CM" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the May issue.



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