A 78-year-old female patient is referred to home health after a hospital stay due to cellulitis of the right foot. The patient developed generalized dermatitis as an adverse reaction to the IV antibiotic Amoxicillin used for the initial treatment while inpatient. Skilled nursing will focus on assessing the cellulitis area and the patient’s response to a new oral antibiotic at home as well as caring for and assessing the contact dermatitis.
| Primary and Secondary Diagnoses | Code |
| M1021a: Cellulitis of right lower limb | L03.115 |
| M1023b: Generalized skin eruption due to drugs and medicaments taken internally | L27.0 |
| M1023c: Adverse effect of penicillins, subsequent encounter | T36.0x5D |
Rationale:
- The cellulitis is the focus of care. Code for this diagnosis as primary.
- When coding an adverse effect, sequence the nature of the adverse effect first; in this case, the generalized dermatitis.
- Report the T code specifying the substance causing the adverse effect as an additional code with the 6th character of five to indicate an adverse effect, and the 7th character “D” to indicate subsequent care for the healing and recovery phase.