# Parenteral controlled substance in ED



## LuckyLily

I would like to confirm that when coding E&M for the emergency department, when a patient gets a IM, IV, etc... of a controlled substance that it is a high level on the MDM risk.


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## Lyta2000

no. to be considered high risk it must be on the CMS list of drugs requiring monitoring for toxicity. IV Heparin is one.


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## LuckyLily

There are two examples given in the Management Options of the MDM table.

-Parenteral control substances
-Drug therapy requiring intensive monitoring for toxicity

I want to know about the Parenteral controlled substances. Lyta2000 are you referring to the Drug therapy.


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## LuckyLily

I was hoping that I would get more replies regarding Parenteral controlled substances that are given in the Emergency Department. For those E/M coders that do ED, is this an area that is not taken into consideration for the MDM risk?


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## pahenkel

The drug has to be considered a controlled substance AND given by injection or infusion (parenteral) in order for it to be considered high risk.


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## nomerz

Risk depends on the route of medication given, i.e. IV dilaudid is high risk while IM dilaudid would be moderate risk. 

Does that answer your question?


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## SKPILLEY

*Sandra Pilley CPC, CPMA*

On the table of risk, under the "high" category it lists "Parenteral Controlled Substances". I've googled the word "parenteral" and it is defined by several sources as: 1) administered or occurring elsewhere in the body than the mouth and alimentary canal. 2) Administered by some means other than oral or rectal intake, particularly intravenously or by injection. 3) medical Definition of parenteral. : situated or occurring outside the intestine. parenteral drug administration by intravenous, intramuscular, or subcutaneous injection ; especially : introduced otherwise than by way of the intestines.
Therefore, I would definitely count it as HIGH RISK if a controlled substance is given by IV or IM. Basically, as long as it is not being given by mouth, rectally, through a feeding tube, or other entrance/means directly into the digestive system.


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## paynejw83

To be credited for high table of risk, "parenteral" controlled substances must be administered by this provider/team, must be a route that is not taken via alimentary tract, and must be on the FDA schedule of parenteral controlled substances, which can be found on the FDA site (updated as of 9/28/2020): https://www.ecfr.gov/cgi-bin/text-i...558e0cd&mc=true&node=se21.9.1300_101&rgn=div8, or, the direct link to the schedule of controlled substances is available (also on the FDA site) here: https://www.ecfr.gov/cgi-bin/text-i...0cd&mc=true&node=sg21.9.1308_103.sg1&rgn=div7  You can then use the "find" function and type in the substance you are looking for to see if it is on the schedule.  Another option is to search the DOJ's DEA Division, which is slightly more user friendly: https://www.deadiversion.usdoj.gov/schedules/

This is different than the table of risk high category for "intense monitoring for drug toxicity" which is usually something that has regularly scheduled labs to check to organ dysfunction as caused by the drug.  For that, Palmetto GBA (our local MAC in VA) has an excellent definition to meet this criteria, as well as drug examples: https://www.palmettogba.com/palmett... B~EM Help Center~General Articles~8EELEJ7715 

I hope this helps!
Jessica Walter, CPC, CPMA, CEMA
Coding Improvement Coordinator


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## natashalage

Thank you very much Jessica for this information! it is very helpful and I will share it in my huddle with other coders Thank you!


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## MaryamParvaiz

If a patient come to free standing ER with abdominal pain and morphine injection is given to relieve pain. can we consider it as high risk ? I guess paraentral controlled  substances must not be taken on high risk if they does not require monitoring. Any suggestions please?


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## paynejw83

MaryamParvaiz said:


> If a patient come to free standing ER with abdominal pain and morphine injection is given to relieve pain. can we consider it as high risk ? I guess paraentral controlled  substances must not be taken on high risk if they does not require monitoring. Any suggestions please?


Hi Maryam, parenteral controlled substances and medications requiring intensive monitoring for toxicity are 2 separate considerations on the table of risk. An IV or injected medication for pain control is more likely to fall under the controlled parenteral administered medication (see my comment above for resources) whereas a drug that required intense monitoring is typically being administered and/or monitored with regular intervals. The risk to the patient, the frequency of labs to determine toxicity,  and the patient status must be documented. This is highly unlikely in the ED setting as this requires frequent monitoring- think immunosupression therapy post transplant, or treatments for malignancy. Of course this is only one area of 3 for MDM consideration in the ED (Tables A, B, and C), and only applies for services through the rest of 2022, after which the new 2023 guidelines will take place.


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