Wiki 977.9 documentation question

[MelDS]

How much documentation is needed to cover this poisoning code? Is this correct code to use? Provider is an NP in a family care clinic. Patient is 11 yrs old and weighs 77 lbs. and was given a 1 1/2 - 2 tbls of over the counter adult cold and flu medication. The NP states the amount of med and what kind was given and that it gave the patient mild relief. Constitutional: Vital signs are normal. He appears well-developed and well-nourished. He appears lethargic. He is sleeping. Non-toxic appearance. He has a sickly appearance. No distress. The NP charted that they called poison control and was told to monitor the patient for 1 - 2 hours. The patient came in with fever and sore throat. Help please.

 

[mitchellde]

The provider must document poisoning as accidental, it does not look like the provider is calling this an accidental overdoes , states the patient received mild relief. The symptoms could be the flu still and not a reaction to the med. I would code the symptoms and not poisoning in this case.

 

[MelDS]

The provider must document poisoning as accidental, it does not look like the provider is calling this an accidental overdoes , states the patient received mild relief. The symptoms could be the flu still and not a reaction to the med. I would code the symptoms and not poisoning in this case.

Thanks so much. After more discussion with the NP, it has been decided not to go with accidental overdose. The NP only states overmedicated, not accidental.

 

[mitchellde]

Overmedicated is the same thing as accidental poisoning. Any time a patient takes or is given more medication than what is prescribed it is a poisoning. For OTC meds if the provider documents that the patient took more than the recommended dosage on the bottle then it is an accidental poisoning. So if the NP documents that the patient overmedicated then you use the accidental poisoning code first listed