Medical Specialty: General Medicine
Description: Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.
HISTORY OF PRESENT ILLNESS: Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets. Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated. The patient was alert and did not vomit during the transport to the emergency room.
Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor. The patient said that the pills “didn’t taste good,” so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.
PAST MEDICAL HISTORY: Baby was born premature and he required hospitalization, but was not on mechanical ventilation. He doesn’t have any hospitalizations after the new born. No surgeries.
IMMUNIZATIONS: Up-to-date.
ALLERGIES: NOT KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION
VITAL SIGNS: Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.GENERAL: Alert, in no acute distress.
SKIN: No rashes.
HEENT: Head: Normocephalic, atraumatic. Eyes: EOMI, PERRL. Nasal mucosa clear. Throat and tonsils, normal. No erythema, no exudates.
NECK: Supple, no lymphadenopathy, no masses.
LUNGS: Clear to auscultation bilateral.
HEART: Regular rhythm and rate without murmur. Normal S1, S2.
ABDOMEN: Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.
EXTREMITIES: Warm. Capillary refill brisk. Deep tendon reflexes present bilaterally.
NEUROLOGICAL: Alert. Cranial nerves II through XII intact. No focal exam. Normal gait.RADIOGRAPHIC DATA: Patient has had an EKG done at the admission and it was within normal limits for the age.
EMERGENCY ROOM COURSE: Patient was under observation for 6 hours in the emergency room. He had two more EKGs during observation in the emergency room and they were all normal. His vital signs were monitored every hour and were within normal limits. There was no vomiting, no diarrhea during observation. Patient did not receive any medication or has had any other lab work besides the EKG.
ASSESSMENT AND PLAN: Three years old male with accidental ingestion of Celesta. Discharged home with parents, with a follow-up in the morning with his primary care physician
Scenario Summary (Coding Context)
A 3-year-old male arrives at the Emergency Department after an accidental ingestion of two to three tablets of “Celesta” 40 mg about 45 minutes before arrival. However, he remains asymptomatic with normal exams. The ED physician consults poison control, observes the child in the ER for six hours with serial EKGs, and then discharges him home.
ICD-10-CM Diagnosis Codes
Primary Diagnosis
T50.901A Poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), initial encounter
Rationale
The documentation identifies an accidental ingestion of a medication. However, “Celesta” does not match a specific drug class in the ICD-10-CM Table of Drugs and Chemicals. When the drug or class is not clearly identified, T50.901A is appropriate. Also, the 7th character “A” is required because this is the initial encounter for the poisoning.
Teaching note: Always confirm the drug before you default to an unspecified code. For example, if the provider confirms the medication was Celexa (citalopram), an SSRI, you would instead report T43.221A. In that situation, a provider query is the right move.
External Cause Codes
In ICD-10-CM, the poisoning T code already includes the intent (accidental). For this reason, you do not need a separate external cause code to describe how the poisoning happened.
Y92.009 Unspecified place in unspecified non-institutional (private) residence (optional)
The ingestion occurred at home. Therefore, this place of occurrence code adds context, although it does not affect payment.
Do not assign an activity code. The guidelines state not to report Y93.9 (activity, unspecified) when the record does not state an activity.
Codes Not Assigned (With Rationale)
Do not report symptom codes such as nausea or vomiting, because the patient remained asymptomatic. In addition, do not report a noncompliance code, since this was accidental, not neglect or misuse. Finally, do not report an adverse effect code, because this is a poisoning, not a reaction to a properly taken medication.
CPT and HCPCS Procedure Codes
Emergency Department E/M
99284 Emergency department visit, moderate level of medical decision making
Rationale
This pediatric ingestion required a poison control consultation, six hours of monitored observation, and multiple EKGs. As a result, it meets moderate MDM despite the stable presentation. In other words, 99283 would generally be too low given the risk profile of a pediatric ingestion.
Electrocardiograms
93000 x 3 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
Rationale
The record documents one EKG at arrival and two more during observation. Each one was performed, interpreted, and documented. However, in the ED setting the physician often reports only the interpretation (93010), while the facility reports the tracing (93005). So, match the code to who performed which component.
Observation Coding
Do not bill hospital inpatient or observation care codes (99221 through 99236). The observation occurred within the ER, and the provider did not formally place the patient in observation status. Consequently, the ED observation time is part of the ED E/M code.
Coding Logic Summary
- Primary diagnosis: T50.901A, accidental medication ingestion, unspecified drug
- Place of occurrence: Y92.009, occurred at home
- E/M: 99284, pediatric poisoning with monitoring
- EKG: 93000 x 3 (or 93010 and 93005, by setting), serial EKG monitoring
Final Notes for Coders
Always confirm the drug classification before you default to T50.901A. Also, pediatric ingestions often support moderate MDM. Keep in mind that ER observation is not an observation admission. Finally, serial diagnostics must be documented before you bill multiple units.
Related Resources
Abstracting from the EHR
Medical Coding OP Reports
How to Approach a Long Medical Coding Exam Scenario
American College of Emergency Physicians