Renee Posted Wed 22nd of September, 2010 14:39:34 PM
Patient comes to the ED after a fall. Patient is on multiple medications and tested positive for alcohol, barbiurates, Benzo, cocaine and opiates. MD states he feels the patient fell because of the alcohol and other medications on board and gives the impression of "Poly-Substance" Would it be appropriate to code '305.90' Does he have to state abuse to assign this code? Thanks.
SuperCoder Answered Thu 23rd of September, 2010 10:54:28 AM
The set of codes included for "Abuse" includes cases where a person, for whom no other diagnosis is possible, has come under medical care because of the maladaptive effect of a drug on which he is not dependent and that he has taken on his own initiative to the detriment of his health or social functioning.
In the given situation, the "Context" of fall is not well documented in HPI. The MD here is the best person to evaluate that whether the fall would have happened because of the "adverse effect" of continuing medications or because the patient has been tested positive for alcohol, barbiturate, Benzo,etc. The MD is in this situation has made his best efforts to evaluate the reason of fall, and had concluded that this is effect of "Nonprescribed use of drugs or patent medicinals" consided as Abuse. Has there been any other indication for the reason of fall, then Dx would have been a different code.