RAC denial for Toxic Encephalopathy
Recently we have received 2 RAC denial for Toxic Encephalopathy G 92. Both patients were admitted with poisoning secondary to taking amitriptyline that was not prescribed for them, both presented with altered mental status and Toxic encephalopathy is consistently documented. RAC is removing the G 92 code and replacing with F13.921 Sedative use unspecified w/intox. delirium. These patients were both discharged before the coding clinic 1st Q 2017 came out. So it does not apply.
We do not feel the use of the F13.921 was appropriate since neither patient had a mental/behavioral diagnosis that supported the use of the amitriptyline.
Is anyone else seeing this? Any supporting thought to combat this?
Comments
What is the 'RAC' rationale? Are they indicating this is a clinical validation issue and/or a technical coding issue? (makes a difference). In a rebuttal, can you cite clinical support, such as GCS scores supporting the condition? Did clinicians document neurological findings consistent with encephalopathy?
P. Evans, RHIA, CCDS
They are denying the claim stating:" In ICD10 there are combination codes that describe various effects of drug use. These combination codes eliminate the need to use additional codes to describe the patient’s mental status, such as encephalopathy and delirium. Coding guidelines state that multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. Alteration in mentation status is inherent to the diagnosis codes in the F10 –F19 series."
When you use poisoning as the PDX using T43.011A there is an Excluded 2 note for use of F 10 - 19 codes. This was my original argument. I was denied again. I have been taught that unless the physician links a metal/behavioral diagnosis with the drug and adverse effect you do not use the F10-19 codes.
There is a coding clinic 1 q 2017 that supports the use of Toxic Encephalopathy due to adverse effect of Ciprofloxacin. Effective March 13, 2017.
Poisoning guideline (Section I.C.19.5.b) states if there is ALSO a diagnosis of abuse or dependence of the substance, the abuse or dependence is assigned as an additional code.