ED Coding and Reimbursement Alert

Question: We recently had a patient in our ED with an insulin reaction. I have been taught that if the patient takes the insulin incorrectly, we are to use a poisoning code and then the E code, both out of the Table of Drugs and Chemicals (In ICD-9-CM). If the patient has a reaction to insulin and took the drug correctly, you should code the symptoms the patient is having and then the E code out of the Table of Drugs and Chemicals. I have been told to stay out of the Adverse Effect chapter (995 codes), and use codes in the Poisoning chapter and that these (the 995 codes) are trash codes. Why is it that ICD-9 has intentionally put insulin reaction in the book as 995.2 and we arent supposed to use this code?

ECA Subscriber

Answer: First, although code 995.2 is indeed listed in the index to diseases as reaction, insulin, if you look up 995.2 in the tablular list, the actual definition of the code is unspecified adverse effect of drug, medicinal or biological substance. A yellow triangle next to the code indicates it is a nonspecific code and should be used only when there is no more specific code available.

Tip: When looking up an unfamiliar diagnosis code in the index of diseases in ICD-9, be sure to also check the tabular list for the complete definition as well as any specific requirements, such as fifth-digit specificity.

You should only use 995.2 when it is unclear what substance is causing the adverse effect, Stradley says. In this case, the substanceinsulinis known.

The 995 set of codes are not trash codes, but their definition indicates that they are for certain adverse effects not elsewhere classified. When coding adverse reactions to drugs, and the specific substance and circumstances of ingestion are known, the Table of Drugs and Chemicals has more specific codes to indicate what happened.

Diagnosis coding for drug reactions requires coders to report the specifics of what caused the reaction, at least as much as is known to the clinician at the time of treatment. According to the guidelines published in the front section of ICD-9-CM, under the heading Coding Difficulties, poisoning codes should be reported when a drug or substance is taken incorrectly, either prescribed by a physician and taken in an inappropriate manner or taken without physician instruction at all (i.e., a child swallowing an overdose of aspirin).

If the patient on insulin took the drug incorrectly, the coder should look up insulin in the Table of Drugs and Chemicals, then report the poisoning code for insulin (962.3) first. The coder would then code any signs and symptoms related to the adverse reaction, (i.e., dizziness, nausea, syncope, etc.). The coder should then report an E code for the external cause of the poisoning. These are also listed next to the name of the drug in the Table of Drugs and Chemicals. For example, if the patient accidentally took too much insulin, the E code for accident listed next to the poisoning code would be reported next (E858.0).

Note: Do not use the E code for therapeutic use in this situation (see below).

However, if a patient takes the insulin (or other drug) correctly and still has an adverse reaction, the coder should first report the codes of the signs and symptoms that indicate that reaction (i.e., fainting, 780.2 or dizziness, 780.4, etc.) Next, the coder should report the E code for therapeutic use found in the Table of Drugs and Chemicals next to the name of the drug. In this case, the code would be E932.3. This code is only used when the drug has been taken according to instructions. However, it is never reported as a primary diagnosis code. The signs and symptoms indicating that patients reaction should be coded first.