# MDM Question - monitoring for toxicity



## jifnif (Feb 18, 2010)

I wanted to know if anyone could give me a few examples of "Drug therapy requiring intensive monitoring for toxicity".  Does IV Lasix quantify under moderate or high mdm?


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## jackieisacoder (Feb 18, 2010)

I worked in intensive care as a unit secretary for 10 yrs. The drugs that come to my mind as toxic, or the ones the doctors ran levels on most frequently were Digoxin/Lanoxin, Theophylline and Aminophylline and some psychiatric drugs.


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## jifnif (Feb 19, 2010)

so here is the note why i wanted to know where to quantify "iv lasix".  the dr is telling me that iv lasix should be marked under high risk for drug therapy inquiring monitoring for toxicity. What do you think?

PLAN:
IV LASIX NOW
REPEAT CXR
STOP ATIVAN - WILL RESUME AT HOME DOSE WHEN PT FULLY AWAKE
CARDIOLOGY CONSULT
MOVE TO TELE

PROBLEM LIST: 
1) Urosepsis
2) Sacral decubiti and possible cellulitis
3) CHF
4) DM2
5) Anxiety
6) Decrease in global functioning / failure to thrive
7) Pain control/neuropathy
8) A Fib 

SUBJECTIVE:
PT NON-VERBAL.  PER HUSBAND A LITTLE MORE AWAKE LAST NIGHT.  NO EVIDENCE OF AGITATION OR PULLING AT IV AND FOLEY PER HUSBAND AND NURSING.  MORE DYSPNEIC PER DTR.

OBJECTIVE:
Item	Value	 Date Time
Patient Temperature	98.3 degrees F	9/18/09 0800
Temperature Source	Axillary	9/18/09 0800
Pulse Rate	72 bpm	9/18/09 0800
Respiratory Rate	28 bpm H	9/18/09 0800
Blood Pressure Assessment	158/68	9/18/09 0800
  Location	Right Upper Arm	
Bedside Pulse Oximetry	93 % L	9/18/09 0015
Sodium Level	143 mmol/L	9/17/09 0545
Potassium Level	4.1 mmol/L	9/17/09 0545
Chloride Level	109 mmol/L	9/17/09 0545
Carbon Dioxide Level	26.7 mmol/L	9/17/09 0545
Blood Urea Nitrogen	33 mg/dL H	9/17/09 0545
Creatinine	0.95 mg/dL	9/17/09 0545
Prothromb Time International Ratio	2.79 INR	9/18/09 0540
Percent Meal Consumed	Bites	9/18/09 0926
Percent Meal Consumed	0%	9/17/09 1815
Bedside Blood Glucose	98 mg/dl	9/17/09 2029
Bedside Blood Glucose	114 mg/dl	9/18/09 0000
Bedside Blood Glucose	146 mg/dl H	9/18/09 0600


PHYSICAL EXAM:
General:  Mod resp distress using abdominal accessory muscles.  
Heart: Regular rate and rythym, no murmur, rub or gallop
Lungs: clear to auscultation bilaterally without wheezes, rales or rhonci
Abdomen: Soft, non-tender, nondistended, + bowel sounds
Extremities: warm and dry without cyanosis, clubbing, 2+peripheral pulses, edema


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## jifnif (Feb 19, 2010)

Oh, also...this is a subsequent visit for a hospitalist and he chose a 99233.  I bumped him down one.  Of course, he got very defensive.  I just needed some clarification to see if I was truly incorrect due to the iv lasix.


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## j.berkshire (Feb 19, 2010)

Your Medicare carrier/MAC may have published guidelines.  My carrier, Palmetto GBA, has written a specific response in their FAQs responding to examples of medications they consider to be high risk:  "Examples of drugs categorized as high risk are most chemotherapy drugs and certain cardiac drugs with narrow therapeutic ranges such as Amiodarone. If you look in a drug book, you will see that Amiodarone is listed as 'toxic', but drugs like Coumadin and Rocephin are not."

A more comprehensive list of high-risk drugs is listed at this link:
http://www.palmettogba.com/Palmetto/Providers.nsf/files/Drug_Therapy_Requiring_Intensive_Monitoring_for_Toxicity.pdf/$FIle/Drug_Therapy_Requiring_Intensive_Monitoring_for_Toxicity.pdf


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## brockorama01 (Feb 19, 2010)

I am looking for guidance on the "toxic" issue as well.  I tend to focus on the term 'high risk' more than 'toxic".

I work with pain management practices who have used Suboxone or Lidocaine infusions, etc. These medications are very effective but have a high risk of pt complications..such as your heart stopping..not just toxicity.

Using this philosophy, I would argue on behalf of the physician.  Lasix can be a high risk drug...even thought the risk isn't necessarily associated with toxicity.  

Don't loose sight of the real issue: the work and risk associated with providing a service.

Brock Berta, CPC


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## FTessaBartels (Feb 19, 2010)

*Table of Risk measures Risk to PATIENT*

The table of risk is a tool to quantify the risk to the PATIENT (not to the doctor). 

You may not want to focus on the toxicity issue, but that is clearly the requirement per the table. 

That being said, I wish more carriers would define this - or even CMS. Because it is SOOOo open to interpretation.

F Tessa Bartels, CPC, CEMC


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## sgoodknight (Jun 6, 2011)

I think the key words are "intensive monitoring" in your original question.  After starting this medication how often was it medically necessary to monitor the levels for possible toxicity?

I think how you answer the question will answer your original posting.

Sandy Goodknight, CPC, CPMA, CEMC
Indiana


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