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Drug Toxicity

Drug Toxicity. Poisoning Vs. Adverse Effect. Introduction. Drug toxicity is very common – 35% of original Star Trek episodes included toxin related events. EPA Definition of Toxicity.

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Drug Toxicity

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  1. Drug Toxicity Poisoning Vs. Adverse Effect Prepared by Amy Brazell, RHIT, CCS, CPC-H

  2. Introduction • Drug toxicity is very common – 35% of original Star Trek episodes included toxin related events Prepared by Amy Brazell, RHIT, CCS, CPC-H

  3. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  4. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  5. Reason for Coding Confusion: • Index under Toxicity: • Drug • Asymptomatic - 796.0 • Symptomatic - See Table of Drugs and chemicals Prepared by Amy Brazell, RHIT, CCS, CPC-H

  6. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  7. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  8. E codes for Drugs • Accidental Poisoning E850-E869 • Therapeutic Use E930-E949 • Suicide Attempt E950-E952 • Assault E961-E962 • Undetermined E980-E982 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  9. Homicides by Poisoning • 2005: 85 homicidal poisonings • ICD10: X85- X90 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  10. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  11. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  12. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  13. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  14. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  15. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  16. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  17. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  18. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  19. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  20. JAKE LEG Prepared by Amy Brazell, RHIT, CCS, CPC-H

  21. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  22. Coding Jake Leg • The singer: Wasn’t taking Jake for therapeutic purposes • 977.8 • Code for jake leg • E858.8 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  23. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  24. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  25. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  26. ICD10 • Unintentional Poisoning deaths: • Codes X45-X49 • The greatest increase was among the “other and unspecified” drugs, psychotherapeutic drugs, and narcotic and hallucinagen drugs. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  27. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  28. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  29. Many reasons for ADRs • Drug-disease interactions • Liver disease • Renal disease • Cardiac disease • Acute viral infection • Hypothyroidism or hyperthyroidism Prepared by Amy Brazell, RHIT, CCS, CPC-H

  30. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  31. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  32. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  33. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  34. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  35. 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: Prepared by Amy Brazell, RHIT, CCS, CPC-H

  36. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  37. Contest • Name some drugs that have been taken off the market Prepared by Amy Brazell, RHIT, CCS, CPC-H

  38. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  39. 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. Prepared by Amy Brazell, RHIT, CCS, CPC-H

  40. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  41. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  42. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  43. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  44. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

  45. 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/ Prepared by Amy Brazell, RHIT, CCS, CPC-H

  46. References • http://master.emedicine.com/email/ecg/ecg21answer.html • http://www.fda.gov/cder/drug/drugreactions/default.htm • Faye Brown’s ICD-9-CM Coding Handbook, 2003, 337-338, 342-343 • http://www.anaes-icu-waikato.org.nz/ICU/downloads/c96b85uf.ppt Prepared by Amy Brazell, RHIT, CCS, CPC-H

  47. 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 Prepared by Amy Brazell, RHIT, CCS, CPC-H

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