Internal Medicine Coding Alert

Question: Encounter notes indicate a patient with uncontrolled type II diabetes had nausea and a brief blackout due to insulin. Should I report a poisoning 962.3 or an adverse reaction?

Illinois Subscriber

Answer: Your code choice depends on whether the patient took the appropriate medication correctly.

Go back to the encounter notes to find out what caused the patient's insulin reaction. If the patient took more than the prescribed amount of insulin, then you would report:

• 962.3 (Poisoning by hormones and synthetic substitutes; insulins and antidiabetic agents) for the overdose

• 780.2 (Syncope and collapse) for the blackout

• 787.02 (Nausea alone) for the nausea

• 250.02 (Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled) for the diabetes

• E858.0 (Accidental poisoning by other drugs; hormones and synthetic substitutes) to represent the cause of the patient's injuries.

But if notes indicate that the patient took the correct amount of insulin at the appropriate administration time, you would not report 962.3. In these cases, you would report:

• 780.2 and 787.02 to represent the patient's presenting symptoms

• 250.02 for the diabetes

• E932.3 (Hormones and synthetic substitutes; insulins and antidiabetic agents) to show that the patient took the correct dosage but still had an adverse reaction.