Toxicology, blood, alcohol, positive: Difference between revisions
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{{ICD10 category|Testing}}{{ICD10 category|Alcohol related | {{ICD10 category|Testing}}{{ICD10 category|Alcohol related}} | ||
== Additional Info == | == Additional Info == | ||
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== Candidate [[Combined ICD10 codes]] == | == Candidate [[Combined ICD10 codes]] == | ||
{{ICD10 Guideline Trauma w mechanism}} | {{ICD10 Guideline Trauma w mechanism}} | ||
== Related CCI Codes == | == Related CCI Codes == |
Revision as of 10:55, 2019 December 11
ICD10 Diagnosis | |
Dx: | Toxicology, blood, alcohol, positive |
ICD10 code: | R78.0 |
Pre-ICD10 counterpart: | Etoh OD/Intoxication |
Charlson/ALERT Scale: | none |
APACHE Como Component: | none |
APACHE Acute Component: | none |
Start Date: | |
Stop Date: | |
External ICD10 Documentation |
This diagnosis is a part of ICD10 collection.
Additional Info
Abnormal test
- This code identifies an abnormal test result, not a disorder.
- The preference is to code the cause of the abnormal test, if known.
- also coding this abnormal test, along with the cause is optional however, it is not necessary.
- When the DX is not known, code likely related other tests and signs and symptoms as Combined ICD10 codes; some likely ones might be listed in #Candidate Combined ICD10 codes.
Symptom/Sign/Test Result not needed when cause known
- This code identifies a symptom or a sign, or an abnormal test result, not a disorder.
- So, you should code the cause of the symptom/sign/abnormal test, if known -- and if you do so, then also coding and combining the symptom/sign/abnormal test result to that cause is generally optional, but is guided by the following guidelines.
- Here are guidelines for whether or not to ALSO code the symptom/sign/abnormal test when you DO code the underlying cause:
- If it is a subjective symptom (e.g. pain) then coding it is optional
- When it is a physical exam finding (e.g. abdominal tenderness) then coding it is generally optional
- An exception is when the symptom/sign/abnormal testis so severe that all by itself it mandates hospitalization and/or a procedure -- a good example is a patient who has Wegener's granulomatosis is admitted due with Hemoptysis. Since hemoptysis is a physical finding that fits this description of "severe" it should be coded, and combined with Wegener's.
- When it is an abnormal laboratory finding which in and of itself has relevance (e.g. hyperkalemia, hypoalbuminemia) then USUALLY code it
- You don't need to code the abnormal lab finding is when it is actually a major component of the underlying cause --- example is when a person presents with an acute MI, there is no need to code the abnormal troponin as Abnormal blood chemistry NOS
- The trickiest of these guidelines is for abnormal radiologic tests
- When the abnormal test is fully explained by the underlying diagnosis/diagnoses (e.g. pneumonia as cause of abnormal chest imaging, or a skull fracture with an intracranial hemorrhage both identified by an abnormal head CT) then coding the abnormal imaging result is optional
- But remember there are some rare things for which the abnormal imaging result IS part of coding the entity, for example we code retroperitoneal hemorrhage by the combination of Hemorrhage, NOS and Retroperitoneal area, diagnostic imaging, abnormal
- Sometimes there may be multiple symptom/sign/test result that might or might NOT be related to each other by virtue of having the same underlying cause. Since in the absence of KNOWING that cause, such assumptions may well be incorrect, do NOT combine them together if you are not certain they actually have the same underlying cause.
Repeated events
If this happens repeatedly during the same ward or unit stay, only code it the first time it happens, regardless of whether it is an Admit Diagnosis or Acquired Diagnosis, rather than each time it happens. See ICD10 codes only coded the first time for other diagnoses coded this way.
Example: |
|
Alternate ICD10s to consider coding instead or in addition
- Toxicology, blood, alcohol, positive
- Toxicology, blood, opiates, positive
- Toxicology, blood, cocaine, positive
- Toxicology, blood, addictive drugs NOS, positive
- Toxicology, urine, illicit drugs, positive
- Alcohol (ethanol) acute intoxication (drunkenness)
Candidate Combined ICD10 codes
Traumas and their Mechanisms
- In ICD10, traumas need to be combined with separate mechanism codes to fully explain the situation.
- Here are lists of the codes for "mechanical" injuries to various body parts:
- some codes are always traumatic and always need a mechanism:
- Other codes may or may not be of a traumatic nature; these also qualify to be coded with trauma mechanisms listed below:
Potential trauma codes: |
- Here is a list of the external mechanism or agent that caused the trauma:
Regarding Multiple Trauma
- When a person has multiple body areas traumatized, code Multiple trauma
- When using Multiple trauma also code the individual things traumatized, e.g. leg, arm, head, etc.
- Code Multiple trauma and all the individual things traumatized as Combined ICD10 codes
- And in this case, assuming that they all have the same mechanism of injury (e.g. Mechanism of injury: motorcyclist), then you'd also code that Mechanism code as the same Combined ICD10 codes.
- If the multiple trauma is the primary admit diagnosis, then among this group of linked ICD10 codes, the Primary Admit Diagnosis would be either the Multiple trauma or the "worst" thing injured, e.g. Brain injury, diffuse (TBI), injury/trauma
Iatrogenic injuries
- Some iatrogenic codes are self-explanatory for what occurred. For example Iatrogenic, air embolism, as complication of line/infusion/transfusion/injection. But for others, such as Iatrogenic, puncture or laceration, related to a procedure or surgery NOS it's not clear what happened, i.e. what was iatrogenically injured.
- In these latter cases, with just one exception, DO NOT also code a trauma code for what was iatrogenically injured. This is because iatrogenic injuries are technically not considered to be traumas.
- that one exception is you should code Rib fracture(s) due to CPR in the context of CPR, cardiac resuscitation.
- Instead, combine the iatrogenic code with another ICD10 code indicating the body part involved.
- e.g. for iatrogenic laceration of a pulmonary artery, combine: Iatrogenic, puncture or laceration, related to a procedure or surgery NOS with Disorder of pulmonary vessels, NOS. See list of NOS codes in ICD10.
- In these latter cases, with just one exception, DO NOT also code a trauma code for what was iatrogenically injured. This is because iatrogenic injuries are technically not considered to be traumas.
Related CCI Codes
Data Integrity Checks (automatic list)
none found
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