Find comprehensive information on overdose diagnosis, including clinical documentation, medical coding (ICD-10 T39.0, T40-T49), poisoning symptoms, toxicology reports, and substance use disorder treatment. Learn about overdose signs, drug toxicity levels, emergency care procedures, and prevention strategies. This resource provides essential information for healthcare professionals, clinicians, and medical coders seeking accurate and up-to-date guidance on overdose management and documentation.
Also known as
Poisoning by drugs, medicaments
Overdoses of drugs and medicinal substances.
Toxic effects of substances
Adverse effects from non-medicinal substances.
Accidental poisoning by drugs
Unintentional overdoses of drugs and medicaments.
Intentional self-harm
Includes intentional overdoses for self-harm purposes.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the overdose intentional?
Yes
Suicide attempt?
No
Adverse effect?
When to use each related code
| Description |
|---|
| Overdose |
| Poisoning |
| Adverse drug reaction |
Coding overdose without specifying the substance leads to inaccurate data and potential claim denials. Use specific T codes.
Confusing accidental vs. intentional overdose impacts severity and billing. CDI must query for intent clarification.
Overdoses often present with other conditions. Failing to code all diagnoses impacts risk adjustment and reimbursement.
Patient presents with suspected overdose, manifesting as [specific signs and symptoms, e.g., altered mental status, respiratory depression, pinpoint pupils, nausea, vomiting]. Onset of symptoms occurred approximately [timeframe] prior to presentation, reportedly following ingestion of [substance if known, or unknown substance]. Patient's medical history includes [relevant past medical history, e.g., history of substance use disorder, prior overdoses, chronic pain, mental health diagnoses]. Current medications include [list current medications]. Physical examination reveals [objective findings, e.g., vital signs, neurological exam, respiratory assessment, cardiovascular exam]. Differential diagnoses include [list potential alternative diagnoses, e.g., hypoglycemia, stroke, seizure, sepsis]. Initial laboratory studies ordered include [list tests, e.g., complete blood count, comprehensive metabolic panel, toxicology screen, urine drug screen, blood alcohol level]. Toxicology screening will help confirm the suspected overdose and identify the involved substance(s). Treatment initiated includes [specific interventions, e.g., administration of naloxone for opioid overdose, activated charcoal, airway management, intravenous fluids, supportive care]. Patient's condition is currently [stable, unstable, critical] and requires [level of care, e.g., continuous monitoring, intensive care unit admission]. Prognosis is [guarded, fair, good] depending on the identified substance, time to intervention, and patient's response to treatment. Plan for ongoing care includes [further investigations, consultations, e.g., psychiatry consultation for substance use disorder, social work consultation for discharge planning]. ICD-10 code T36.9X5A, Poisoning by unspecified drug, medicinal and biological substance, accidental (unintentional), initial encounter, will be used pending confirmation of specific substance. CPT codes for evaluation and management, laboratory testing, and treatment procedures will be documented accordingly. This documentation will be updated as new information becomes available.