Wiki Allergic reaction due to antibiotic - ICD- 9 code

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sheilacpc

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A coding question, please:

Pt presents to ED with complaints of hives, itching and scratchy throat, currently on antibiotics for bronchitis.

Provider final diagnosis statement: "Allergic reaction, bronchitis"..

Please share your opinions on what the current diagnosis(s) is based on current coding guidelines?

In addition, is there documentation/current coding guidelines that state coding professionals are allowed to link signs and symptoms from the chief complaint/HPI and assume they are related to the allergic reaction if the provider has not documented as such...

Thanks,

Sheila
 
Debra, thanks...

No exam note... It was a coding scenario presented to me.

Rationale is that based coders are allowed to assign codes signs and symptoms for drug reactions (correct drug taken as ordered) even if there is no correlation documented that the signs and symptoms are related---as long as they are mentioned any where in the note...

ICD-9 guidelines state:
When the drug was correctly prescribed and properly administered, code the reaction plus the appropriate code from the E930-E949 series. Codes from the E930-E949 series must be used to identify the causative substance for an adverse effect of drug, medicinal and biological substances, correctly prescribed and properly administered. The effect, such as tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure, is coded and followed by the appropriate code from the E930-E949 series.

I get that the "effect" aka signs/symptoms of the drug reaction should be documented first followed by the E code, etc. if the provider makes the correlation with a statement (or somewhere in the progress note) such as "allergic reaction of hives due to antibiotic" or something of that nature.

I don't get how coders can assume that a patient presenting with "hives" and taking antibiotics for bronchitis that hives should be coded as such as an allergic reaction of the antibiotic UNLESS the provider documented it as such...

I understand that Coding Clinic instructs us to code documented signs/symptoms of an adverse reaction to a drug FIRST and then the E code that corresponds, etc.

The key word is "documented"... If the provider did not make the link between the signs and symptoms and the allergic reaction, how can we as coders "assume" such?

Any and all thoughts with supporting guidelines are appreciated.

Thanks,

Sheila
 
That is why I inquired regarding the exam note. Many times the diagnostic statement does not say everything but in the exam note the correlation is made. I agree without the provider documentation the coder cannot determine that the patient chief complaint has a relationship to the provider diagnostic statement.
 
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