ICD 10 Coding Alert

Know where to go to capture the reason behind a patient’s noncompliance.

Amid the frenzy of ICD-10’s implementation, you may have missed the addition of important concepts like underdosing, which occurs when a patient takes less of a medication than the physician or manufacturer’s instruction prescribed. Now that you’ve had some time to adjust to the new code set, it is the perfect time to fine-tune your skills and learn more about the concepts you may have overlooked.

Read on to understand how underdosing codes can show you a more complete picture of your patients’ health and to make sure you are aware of your underdosing documentation options.

Understand Importance of Underdosing Codes

The ICD-10 underdosing codes have proven helpful because physicians have seen an increase in cases of underdosing and the medical conditions associated with underdosing, according to Suzan Hauptman, CPC, CEMC, CEDC, senior principal of ACE Med Group in Pittsburgh, Pa.

For the new year, organizations like CMS, the Centers for Disease Control (CDC), and the World Health Organization (WHO), will focus on outcomes such as why patients are not showing improvement in their conditions like they should, based on the prescriptions they are given, says healthcare coding educator, auditor, and management consultant Terry A. Fletcher BS, CPC, CCC, CEMC, CCS-P, CCS, CMSCS, CMCS, CMC, ACS-CA, SCP-CA, of Terry Fletcher Consulting.

Put Underdosing Codes Into Action

Imagine this scenario: Mr. Smith visits his cardiologist, Dr. Eldridge, because Mr. Smith’s blood pressure is abnormally high. In a previous encounter, Dr. Eldridge prescribed Norvasc, an amlodipine besylate used to treat high blood pressure and angina. During the exam, Dr. Eldridge learns from Mr. Smith that the patient recently lost his job and is having trouble making ends meet. Mr. Smith says he has skipped doses of his medication because of the high cost. What codes should you report?

Step 1: Report the medical condition.

ICD-10 indicates that you should never choose an underdosing code as the principal or first-listed code. If the physician prescribes a drug for the patient’s medical condition, and the patient’s condition becomes worse because of the reduction in dose, code the condition first.

In the case of our example, you would identify the unintended increase in blood pressure, I10 (Essential [primary] hypertension), caused by the patient skipping doses of his medication.

Step 2: Specify the underutilized drug.

To complete this step, you would look to Chapter 19 and pick a code from categories T36-T50 (Poisoning by, adverse effects of and underdosing of drugs, medicaments, and biological substances).

Note: For underdosing, your fifth or sixth character will always be “6.” The position of the 6 varies by code, so be sure to check the Index and the Tabular to confirm your code choice.

For our example, you would report T46.1X6A (Underdosing of calcium-channel blockers, initial encounter).

Step 3: Identify how the underdosing occurred.

To report underdosing, you will choose a code either for noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9). As the sections below explain, these codes offer more information as to why the patient is not taking his medication as prescribed.

Learn Dosing Intent From Z Codes

Z codes explain the reason behind a patient’s noncompliance, and the codes are broken into two different categories: intentional and unintentional.

Remember, medical record documentation is key to substantiate patients’ noncompliance with taking their meds, says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J.

Check out your noncompliance code options below.

Intentional:

• Z91.120, Patient’s intentional underdosing of medication regimen due to financial hardship
• Z91.128, Patient’s intentional underdosing of medication regimen for other reason

Unintentional:

• Z91.130, Patient’s unintentional underdosing of medication regimen due to age-related debility
• Z91.138, Patient’s unintentional underdosing of medication regimen for other reason

For our example, because the documentation supported the reason for the patient’s noncompliance (financial hardship), you would report Z91.120.

Underdosing due to financial hardship is a common issue, according to Fletcher.

“We don’t have enough data on it yet, since this is a fairly new concept in reporting, but based on documentation audits I have performed over the years and reviewing medical records, it is very common and is linked to financial hardship more than anything,” Fletcher adds.

Hauptman also addresses the concern with patients underdosing because of financial reasons.

“As co-insurance amounts increase and deductibles skyrocket, patients are trying to make their medications last longer, which will give them the ability to stretch their dollars,” says Hauptman. “As a result, they don’t fully feel the effects of the prescribed treatment set forth by the physician.”

Opt for Y Codes When Underdosing Relates to Medical Care

In cases where underdosing was due to medical care, not patient noncompliance, you’ll choose a code from category Y63.- (Failure in dosage during surgical and medical care…). Our example does not involve this situation, but the rule is important to know for those times the situation does occur. Your options for complication of care codes are as follows:

• Y63.6, Underdosing and nonadministration of necessary drug, medicament, or biological substance
• Y63.8, Failure in dosage during other surgical and medical care
• Y63.9, Failure in dosage during unspecified surgical and medical care.