Q&A: Physician documentation related to substance overdoses
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Q: What do you suggest the providers write to describe medication/substance overdose? In my experience, physicians don’t write “poisoning” in these cases.
A: First, I’d refer you to the Official Guidelines for Coding and Reporting, p. 76, related to Chapter 19 of the code set.
According to the Guidelines, the provider does not have to state the occurrence of a poisoning. The provider must, however, clearly state the fact that the medication was either prescribed or administered incorrectly for the application of the appropriate poisoning code to be applied.
The provider must also state whether the intent was either intentional or not. The provider must describe the manifestation of the poisoning as well.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.