documenting underdosing
UNDERDOSING
Terminology Difference
Underdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less of a medication than is prescribed.
When documenting underdosing, include the following:
1. Intentional, Unintentional, Non-compliance Is the underdosing deliberate? (e.g., patient refusal)
2. Reason Why is the patient not taking the medication? (e.g. financial hardship, age-related debility)
DIABETES MELLITUS, HYPOGLYCEMIA AND HYPERGLYCEMIA
Increased Specificity
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.
When documenting underdosing, include the following:
1.Type e.g. Type 1 or Type 2 disease, drug or chemical induces, due to underlying condition, gestational
2. Complications What (if any) other body systems are affected by the diabetes condition? e.g. Foot ulcer related to diabetes mellitus
3. Treatment Is the patient on insulin?
A second important change is the concept of “hypoglycemia” and “hyperglycemia.” It is now possible to document and code for these conditions without using “diabetes mellitus.” You can also specify if the condition is due to a procedure or other cause.
The final important change is that the concept of “secondary diabetes mellitus” is no longer used; instead, there are specific secondary options.
Z91.120 Patient’s intentional underdosing of medication regimen due to financial hardship T36.4x6A Underdosing of tetracyclines, initial encounter T45.526D Underdosing of antithrombotic drugs, subsequent encounter
ICD-10 Code Examples
16
INJURIES
Increased Specificity
ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins.
When documenting injuries, include the following:
1. Episode of Care e.g. Initial, subsequent, sequelae
2. Injury site Be as specific as possible
3. Etiology How was the injury sustained (e.g. sports, motor vehicle crash, exposure?)
4. Place of Occurence e.g. School, work, etc.
Initial encounters may also require, where appropriate:
1. Intent e.g. Unintentional or accidental, self-harm, etc.
2. Status e.g. Civilian, military, etc.
E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma R73.9 Transient post-procedural hyperglycemia R79.9 Hyperglycemia, unspecified
ICD-10 Code Examples
Example 1: A left knee strain injury that occurred on a private recreational playground when a child landed
incorrectly from a trampoline:
• Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
ICD-10 Code Examples
