Question: We have a patient who presented to the emergency department (ED) with swelling of the lips, tongue, and throat. They were diagnosed with angioedema. It was noted in the chart that the patient’s cardiologist recently prescribed an angiotensin-converting enzyme (ACE) inhibitor. Should this be reported with an adverse effect code?
Nevada Subscriber
Answer: To code for an adverse effect, the two conditions must be linked. The driving factor will be provider documentation.
ACE inhibitors are a class of medications that are primarily used to treat conditions like high blood pressure and heart disease. These medications help regulate blood pressure and blood flow by relaxing the veins and arteries. This is accomplished by preventing the formation of angiotensin II, a hormone that constricts blood vessels. Angioedema can be a rare but potentially life-threatening side effect of ACE inhibitors. Common symptoms of drug-induced angioedema are swelling of the face, mouth area, and throat. Some patients may also experience abdominal pain secondary to intestinal angioedema.
Given this patient’s symptoms and the chart note about the recently prescribed ACE inhibitor, it is likely that this is an adverse reaction. If documented appropriately, proper coding for drug-induced angioedema secondary to ACE inhibitors would be T78.3XXA (Angioneurotic edema, initial encounter) followed by T44.5X5A (Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounter). Following coding guidelines, however, coders cannot assume a causal relationship even though both have been noted in the history or assessment. Allergic reactions, infections, or an autoimmune disorder are some other potential causes of angioedema. It is crucial that the provider directly link the manifestation to the adverse effect to help paint a better clinical picture and support the relationship between the two conditions in the documentation.
To attribute the angioedema as an adverse effect of the ACE inhibitor, the provider would need to explicitly state that in their note. A good first step would be to query the provider for clarification if the relationship is unclear. Otherwise, when the conditions are not linked, only code the angioedema, T78.3XXA, and any other symptoms or relevant conditions listed in the documentation.
Brittany Sowards, BA, CPC, CPMA, CCC, CCVTC, Clinical Documentation Specialist
