# Insulin - High risk med??



## Love Coding! (Aug 8, 2016)

Hi,

I need someone to shed some light on this for me.  When would you consider Insulin to be a high risk med?  I have read it's only considered "high" risk when it's given in IV form under emergent circumstances and I have also read in a clinic setting (follow up office) without insulin can pose a threat to life.  But I am having a hard time wrapping my head around if a patient is insulin dependent, but labs are within normal limits, dosage remains the same or tweaked slightly and have a "high" level of risk.  

I have tried to find direction through Noridian Jurisdiction F, no guidance.  Does anyone know where I can find information to explain when insulin under certain cicumstances is considered a "high" risk med?

Thank you so much in advance!


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## Love Coding! (Aug 8, 2016)

Love Coding! said:


> Hi,
> 
> I need someone to shed some light on this for me.  When would you consider Insulin to be a high risk med?  I have read it's only considered "high" risk when it's given in IV form under emergent circumstances and I have also read in a clinic setting (follow up office) without insulin can pose a threat to life.  But I am having a hard time wrapping my head around if a patient is insulin dependent, but labs are within normal limits, dosage remains the same or tweaked slightly and have a "high" level of risk.
> 
> ...



Anyone?


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## danskangel313 (Aug 8, 2016)

I don't think it's necessarily the actual insulin itself causing the risk to be high, I think it's the circumstances in which the insulin is a component of the situation. Think of a patient who is insulin dependent having a spike in blood sugar while in the waiting room at the doctor's office. What if that office has no insulin on hand? At the same time, insulin that IS on hand needs to be regularly monitored for expiration dates and so forth, which may not always happen. Placing a patient in an environment in which no insulin is readily available poses a problem in and of itself. Insulin becomes high risk for under-dosing complications.

If a patient is given insulin in an emergent situation, you would most certainly need to know the appropriate dosage they usually require, when they had the last dose, and so forth. If you're administering insulin, or any drug for that matter, through an IV, there's pretty much no going back due with that method of administration as it's directly into the bloodstream. What if too much is given or too little? Again, it's a risk for over or under-dosing and that risk definitely becomes high if an overdose occurs through an IV. 

Personally, I would also consider insulin high risk if a patient suffers from a HIGHLY insulin dependent type of diabetes. The risk being what complication would likely arise if a patient like this was without it. I can't find anything specific on just insulin itself being high risk, but I still stand by my opinion that it's the situation or circumstance driving the insulin into a high risk category, not the insulin on its own.


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## Love Coding! (Aug 8, 2016)

danskangel313 said:


> I don't think it's necessarily the actual insulin itself causing the risk to be high, I think it's the circumstances in which the insulin is a component of the situation. Think of a patient who is insulin dependent having a spike in blood sugar while in the waiting room at the doctor's office. What if that office has no insulin on hand? At the same time, insulin that IS on hand needs to be regularly monitored for expiration dates and so forth, which may not always happen. Placing a patient in an environment in which no insulin is readily available poses a problem in and of itself. Insulin becomes high risk for under-dosing complications.
> 
> If a patient is given insulin in an emergent situation, you would most certainly need to know the appropriate dosage they usually require, when they had the last dose, and so forth. If you're administering insulin, or any drug for that matter, through an IV, there's pretty much no going back due with that method of administration as it's directly into the bloodstream. What if too much is given or too little? Again, it's a risk for over or under-dosing and that risk definitely becomes high if an overdose occurs through an IV.
> 
> Personally, I would also consider insulin high risk if a patient suffers from a HIGHLY insulin dependent type of diabetes. The risk being what complication would likely arise if a patient like this was without it. I can't find anything specific on just insulin itself being high risk, but I still stand by my opinion that it's the situation or circumstance driving the insulin into a high risk category, not the insulin on its own.



Thank you, I see this very much as you do.  I was hoping that there was some sort of guideline that I can present to my physicians.  I appreciate the feedback! Have a great evening


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## thomas7331 (Aug 9, 2016)

I recently found this really good article addressing this very question - I've pasted the link below. 

http://thehappyhospitalist.blogspot.com/2013/03/drug-therapy-requiring-intensive.html

I agree with the argument in this article - whether or not a particular medication should be considered high risk in the context of an E&M encounter really depends on the documentation.  The designation of this on the table of risk in the E&M guidelines is just that, a guideline - it's up to the provider to identify the patient's level of risk in the records and, ideally, shouldn't be up to a coder/auditor to try to make their own interpretation.


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## danskangel313 (Aug 9, 2016)

thomas7331 said:


> I recently found this really good article addressing this very question - I've pasted the link below.
> 
> http://thehappyhospitalist.blogspot.com/2013/03/drug-therapy-requiring-intensive.html
> 
> I agree with the argument in this article - whether or not a particular medication should be considered high risk in the context of an E&M encounter really depends on the documentation.  The designation of this on the table of risk in the E&M guidelines is just that, a guideline - it's up to the provider to identify the patient's level of risk in the records and, ideally, shouldn't be up to a coder/auditor to try to make their own interpretation.



I also agree with this information; though personally, I'd still include the situational context and circumstances. Would you agree that the whole idea or concept would apply not only to medications that a person _needs_ to take as well as meds that a person shouldn't be taking?
I'm not sure if this would be a good example to try to better explain what I'm getting at, but here it is anyway. I developed a staph infection requiring a lengthy hospitalization and several infectious disease specialists to figure out what it was, during which they also discovered that the damage done triggered me to be allergic to nearly everything (reasons unknown). So now, every time I have to take any medication, the doctor has to sit and debate the risks that would normally not be considered risks for an average person. No exaggeration here, I mean, I'm allergic to tape, the kind that you'd use to wrap a present. If I handle any type of NSAID in tablet (non-coated) form, I immediately have a reaction, just from contact and straight to the ER I have to go. So if I'm in need of an antibiotic say and the doc is trying to choose which to prescribe, could that not also qualify as a potentially high risk medication with regards to the potential of a severe allergic reaction? Sure, the documentation can explain what NOT to prescribe me, but it doesn't indicate the "unknowns." IMO, the level of MDM needed is substantially higher in instances like this.

I guess my point is, documentation can be relied upon to a certain extent, depending on what information is known, but other factors should be considered as well. High risk could also be applied to meds that would cause a negative reaction IF given, as well as "IF NOT" given.


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