Home Health ICD-9/ICD-10 Alert

For poisonings, include at least three codes.

You might not give the E code section of your ICD-9 manual much thought, since reporting E codes is generally optional in home health. But when your patient suffers an adverse effect from a medication properly prescribed and taken or correctly administered, you are required to use an E code to describe the circumstances. Crack open your coding manual and give yourself a refresher on this often overlooked section.  

Basics: E codes describe the external causes of injury and poisoning. In other words, they describe the "how, where and why of injuries and adverse events," said Sparkle Sparks, MPT, HCS-D, COS-C, consultant with Redmond, WA-based OASIS Answers, during her recent Eli audio conference, "Everything You Always Wanted to Know About V & E Codes But Were Afraid to Ask." 

Key: When the adverse effect occurs despite everyone following the medication regimen correctly, home health coders are mandated to assign an E code from the E930 to E949 series (Drugs, medicinal and biological substances causing adverse effects in therapeutic use), advises Sparks. This guidance comes from section I.C.19.c.7 of the chapter-specific coding guidelines

"I'm often asked, 'Will it affect my reimbursement if I don't use the E code?'" says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. The answer is "no," but reimbursement isn't the foremost reason you should strive to code correctly. Coders must follow the coding guidelines to comply with the HIPAA transaction and coding set regulations, she explains.


Poisoning Or Adverse Effect?

To code for a poisoning or the adverse effects of drugs and other chemicals, you must first determine whether the patient was poisoned or whether it was merely an adverse effect. 

Entries in the medical record that indicate poisoning include "wrong substance" or "wrong dose" taken, "wrong person" taking the substance, "overdose" or "intoxication," says Sparks. "With poisoning, the word you see over and over again is 'wrong.' "

Terms that cue you to code for therapeutic-use adverse effects (for which an E code is required in home health) include "allergic," "idiosyncratic" or "paradoxical" reactions, "cumulative effect" or "toxicity," Sparks says.

Tip: The term to be careful with here is "toxicity," Sparks says. Although it might sound like poisoning, it's actually a synonym for cumulative effect.

"Cumulative effect" may mean that the patient isn't metabolizing the drug adequately and it is accumulating in the blood, says Selman-Holman.


Sequence Poisoning, Adverse Effects Correctly

Once you know whether you're dealing with a poisoning or with adverse effects, you'll need at least two or three codes (depending on the circumstances) to properly report your patient's condition.

You'll also need to familiarize yourself with the Table of Drugs and Chemicals in your ICD-9 manual (See the accompanying article, "Make Adverse Effects Coding A Breeze -- Get To Know The Table Of Drugs And Chemicals," for more on that topic.)

When you report a poisoning, you also need to list the E code for the intent of the poisoning -- whether it was accidental, a suicide attempt or an assault, says Selman-Holman.

Warning: Be careful about reporting E codes for assault and suicide unless you are absolutely positive, Selman-Holman cautions. "You don't want to get a subpoena or be responsible for someone's life insurance cancellation," she says.


1. To describe a poisoning. List the poisoning first, followed by what happened to the patient because he was poisoned, and then report the E code to describe the circumstances of the poisoning.


Coding example: Your patient woke up lethargic due to an unintentional overdose of Ambien.

An accidental overdose is considered a poisoning, Sparks says. To code for this patient, she suggests reporting the following codes:


• M0230a: 967.9 (Poisoning by sedatives and hypnotics; sleeping pill, NOS);

• M0240b: 780.79 (Lethargy); and

• M0240c: E852.9 (Accidental poisoning by other sedatives and hypnotics; sleeping pill NOS).

Code 967.9 describes the poisoning. Next, 780.79 explains what happened to the patient (lethargy) because of the poisoning. Finally, E code E852.9 shows that this was an accidental poisoning.

Why use the E code for sleeping pill, NOS? Although you know which sleeping pill the patient overdosed on, there is no specific entry for Ambien in ICD-9-CM, Sparks says. If you can't find the specific drug name or generic, you must code for the category -- a sleeping pill in this case, she says.


2. To describe an adverse effect due to an ex-ternal cause. Sequence what happened to the patient (the adverse effect) first, followed by the E code that indicates which drug or drugs were responsible for that kind of adverse effect.


Coding example: Your patient has a bleeding gastric ulcer due to aspirin intake for rheumatoid arthritis. The patient has correctly taken the aspirin, which was properly prescribed for the rheumatoid arthritis. For this patient, Sparks suggests listing:


• M0230a: 531.40 (Gastric ulcer; chronic or unspecified with hemorrhage; without mention of obstruction);

• M0240b: E935.3 (Drugs, medicinal and biological substances causing adverse effects in therapeutic use; aspirin); and

• M0240c: 714.0 (Rheumatoid arthritis).


Code 531.40 explains what the adverse effect was -- what happened to the patient. Next, E code E935.3 describes the cause of the adverse effect.

Listing 714.0 explains why the patient was taking the aspirin and paints a more complete picture of the patient, Sparks says. And you could choose to sequence 714.0 before the E code, she says. "The critical thing here is that we must sequence what happened to the patient first and then report the therapeutic use of aspirin, which was responsible for that adverse effect."