Transcript Drug Toxicity - South Carolina Health Information

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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CCS, CPC-H
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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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CCS, CPC-H
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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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CCS, CPC-H
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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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CCS, CPC-H
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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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CCS, CPC-H
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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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CCS, CPC-H
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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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CCS, CPC-H
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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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CCS, CPC-H
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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/chrt
Withdrawals.html
• http://www.fda.gov/cder/biologics/recalls.ht
m
• http://www.fda.gov/cder/reports/rtn/2002/rt
n2002-3.HTM
• http://www.drug-warnings.com/
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References
• http://master.emedicine.com/email/ecg/ecg
21answer.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-icuwaikato.org.nz/ICU/downloads/c96b85uf.p
pt
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References
• http://www.cpsc.gov/neiss/completemanua
l.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
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