QUESTION:
How is this coded?
SCENARIO:
The patient, a young woman, collapsed at a party at her friends parents’ house. Friends called 911 and an ambulance brought her to the emergency department in severe hypoxic respiratory failure and she was intubated in the field. She was put on ventilatory support once she arrived at the ED and was admitted. After 3 days, she regained consciousness and was extubated. After discussions with the provider, she confirmed what was found in her bloodwork, that she abused Valium, cocaine, marijuana. She also admitted to being very drunk after drinking vodka with a blood alcohol level of 210.
Discharge diagnoses: Respiratory failure secondary to overdoses of multiple substances.
ANSWER:
T42.4x1A: Poisoning by benzodiazepines, accidental (unintentional), initial encounter
T40.5x1A: Poisoning by cocaine, accidental (unintentional), initial encounter
T40.711A: Poisoning by cannabis, accidental (unintentional), initial encounter
T51.0X1A: Toxic effect of ethanol, accidental (unintentional), initial encounter
J96.01: Acute respiratory failure with hypoxia
F10.929: Alcohol use, unspecified with intoxication, unspecified
Y90.7: Blood alcohol level of 200-239 mg/100 ml
Y92.018: Other place in single-family (private) house as the place of occurrence of the external cause
5A1945Z: Respiratory ventilation, 24 – 96 consecutive hours
Comments: When multiple drugs are responsible for an overdose/poisoning, a code is assigned for each substance. Any of the poisoning codes can be assigned as the principal diagnosis. The accidental intent is included in the poisoning code. Unless an intentional overdose or suicide attempt is documented, we always give the patient the benefit of the doubt and code to accidental intent.
Acute respiratory failure is the manifestation of the poisoning, but the poisoning codes must be sequenced first. The patient was intubated in the field, so the intubation is not coded here. The patient was on ventilatory support, which qualifies as "Performance" for the root operation.
She admitted intoxication, but no abuse or dependence was documented, so we would only code intoxication here. We also have documentation of a blood alcohol level but remember that the BAL is now one of those diagnoses where the coder can find that information from any clinician in the chart, it does not have to be documented by the provider. We also know the place of occurrence so we would code that as well.
