Primary Care Coding Alert

Question: An established patient with uncontrolled type II diabetes who is on insulin and has dizziness and a headache reports to the physician. The patient says that she forgot to take her insulin for a few days and attempted to "make up" the lost doses with extra injections. During a level-three E/M, the physician determines the patient had an accidental overdose. How many diagnosis codes should I report?

Missouri Subscriber

Answer: You-ll need five ICD-9 codes in order to capture all of the patient's ailments for this encounter.

Code order: When reporting all of these codes, be sure to place them in the proper order on the claim. If a patient has taken the wrong drug or takes the correct drug in the incorrect dosage, you should first report the poisoning code for the drug taken. Then report ICD-9 codes for signs and symptoms that indicate the manifestation of the poisoning.

Third, you should choose the appropriate E code to indicate the external cause of the poisoning. Finally, include an ICD-9 code to represent the patient's underlying condition.

On the claim, report 99213 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the E/M.

And be sure to append the following diagnosis codes, in this order, to 99213 to explain the specifics of the encounter:

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

- 780.4 (Dizziness and giddiness) for the dizziness

- 784.0 (Headache) for the headache

- E858.0 (Accidental poisoning by other drugs; hormones and synthetic substitutes) to represent the cause of the overdose

- 250.02 (Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled) to represent the patient's diabetes.