Admissão para teste de alergia

"Criança saudável, assintomática, admitida para teste de alergia a antibiótico.
 Toma Amoxicilina per-os e desenvolve rash.
 É lícito codificar como diagnóstico principal a admissão para teste?
 
 Z01.82      Encounter for allergy testing 
 L27.0        Generalized skin eruption due to drugs and medicaments taken internally
 T36.0X5A Adverse effect of penicillins, initial encounter"

(Responde Fernando Lopes)
 
(ou L27.1 Localized skin eruption due to drugs and medicaments taken internally)
 
 
É verdade que o diagnóstico principal é definido depois do estudo do doente.
E a conclusão, neste caso, é que existia mesmo alergia ao antibiótico.
No entanto alguns códigos Z são especiais e, segundo as Guidelines:
 
- se numa admissão para rastreio (screening, Z11-Z13) se descobrir patologia, esta é codificada como diagnóstico adicional:
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis. (ICD-10-CM Official Guidelines for Coding and Reporting, FY 2019, Page 98 of 120)
 
- se a admissão for de rotina, o que se encontrar é codificado como adicional:
During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. (ICD-10-CM Official Guidelines for Coding and Reporting, FY 2019, Page 103 of 120) .
 
- se a admissão for para exames pré-operatórios, o que se encontrar também é codificado como diagnóstico adicional:
For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation. (ICD-10-CM Official Guidelines for Coding and Reporting, FY 2019, Page 114 of 120)
 
 
As admissões para testes e para exames têm sido, recorrentemente, causa de muitas dúvidas. 
É útil, por isso reler as Guidelines a este respeito:
 
Routine and administrative examinations
 
The Z codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition.
 
Some of the codes for routine health examinations distinguish between “with” and “without” abnormal findings. Code assignment depends on the information that is known at the time the encounter is being coded. For example, if no abnormal findings were found during the examination, but the encounter is being coded before test results are back, it is acceptable to assign the code for “without abnormal findings.” When assigning a code for “with abnormal findings,” additional code(s) should be assigned to identify the specific abnormal finding(s).
 
Pre-operative examination and pre-procedural laboratory examination Z codes are for use only in those situations when a patient is being cleared for a procedure or surgery and no treatment is given.
 
The Z codes/categories for routine and administrative examinations:
Z00 Encounter for general examination without complaint, suspected or reported diagnosis
Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
Z02 Encounter for administrative examination 
Except: Z02.9, Encounter for administrative examinations, unspecified
Z32.0- Encounter for pregnancy test
 
(ICD-10-CM Official Guidelines for Coding and Reporting, FY 2019, Page 103 of 120)
 
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