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2025 ICD-10-CM code T38.0X5A

Adverse effect of glucocorticoids and synthetic analogues, initial encounter.

Follow the official ICD-10-CM coding guidelines, particularly those related to adverse effects and poisoning.Always code the underlying condition first, then the adverse effect.Use additional codes as necessary to fully capture the clinical picture.Pay close attention to the instructions in the Tabular List for Chapter 19 (Injury, poisoning and certain other consequences of external causes).

Modifiers may be applicable depending on the circumstances of the encounter and the services rendered. Consult the official modifier guidelines for specific applications.

Medical necessity for this code is established when an adverse reaction to glucocorticoids or their synthetic analogues is documented. This requires clear evidence of a causal relationship between the medication and the observed adverse effect, supported by clinical findings and diagnostic testing.

The clinical responsibility lies with the physician managing the patient's treatment and monitoring for adverse drug reactions. This includes diagnosis, appropriate management of the adverse effect, and documentation of the event.

IMPORTANT Additional codes may be necessary to specify the nature of the adverse effect (e.g.,codes from other chapters to describe specific organ system involvement) andthe specific glucocorticoid involved.Consider using additional codes from category T36-T50, specifying the drug with a 5th or 6th character to identify the specific glucocorticoid involved.For subsequent encounters, use the appropriate 7th character (A, D, or S).

In simple words: This code is used when someone has a bad reaction to a type of steroid medicine (like cortisone) for the first time.The doctor will use this code along with other codes to explain exactly what happened.

This ICD-10-CM code classifies the initial encounter for an adverse effect resulting from the use of glucocorticoids and their synthetic analogues.Glucocorticoids are a class of steroid hormones with anti-inflammatory effects, often used to treat various conditions.This code is applied when a patient experiences a negative reaction directly attributable to the administration of these medications.The adverse effect itself should be further specified using additional codes as needed.

Example 1: A 60-year-old female patient with rheumatoid arthritis receiving prednisone develops severe hypertension and hyperglycemia following an increase in her prednisone dosage.Code T38.0X5A would be used along with codes for the hypertension and hyperglycemia., A 35-year-old male patient on a post-transplant course of methylprednisolone experiences significant immunosuppression and opportunistic infections. T38.0X5A is used with codes specifying the infections and the degree of immunosuppression., A 10-year-old child taking oral fluticasone for asthma develops cataracts. Code T38.0X5A is used, in addition to codes describing the cataract formation and its impact on vision.

Detailed documentation should include: the specific glucocorticoid administered, the dosage, route of administration, the date of administration, the onset, type, and severity of the adverse reaction, and any treatments provided for the adverse event.Supporting laboratory results and other relevant clinical findings should also be documented.

** This code should be used for initial encounters only.For subsequent encounters related to the same adverse event, use the appropriate 7th character (A for subsequent encounter, D for subsequent encounter due to the same condition, S for sequela).

  • Payment Status: Active
  • Specialties:Endocrinology, Rheumatology, Immunology, Allergy, and Internal Medicine
  • Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Emergency Room
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