Practice Management Alert

Document the insufficient usage of medication to help paint a more complete picture of a patient’s condition.

If clinicians in your practice prescribe medications, there is a good chance that some patients are underdosing. You and your staff can tidy up your ICD-10-CM knowledge — and focus on bettering your patient care — by fully understanding what underdosing is and what it means for your practice and patients.

“Amid the frenzy of ICD-10’s implementation a couple years ago, you may have missed the addition of important concepts like underdosing, which occurs when a patient takes less of a medication than a physician or manufacturer instruction prescribed,” says Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

In 2019, organizations like Medicare, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) are focusing on outcomes such as why patients are not showing improvements like they should based on the prescriptions they’re given, Fletcher says.

Underdosing Can Majorly Affect Outcomes

Although it may come as a surprise, underdosing could be a major factor in why some of your patients aren’t improving at the rate or on the timeline your clinician expects. If your clinician doesn’t realize that the patient isn’t taking the prescribed amount or type of medication, then she may order more diagnostic tests or schedule more appointments to check up on the patient, meaning spending more time and money.

Knowing how to navigate the ICD-10-CM coding of underdosing can help staff paint a more complete picture of a patient’s health while ensuring comprehensive documentation as well.

“Underdosing medication codes can show you a more complex picture of your patient’s health and make sure you’re aware of your underdosing medication documentation options. ICD-10 CM underdosing codes have proven helpful because physicians have increase in cases of underdosing and the medical conditions associated with underdosing,” Fletcher says.

Context: “We don’t have enough data on it yet because it’s a fairly new concept in reporting, but based on the documentation audits I’ve been performing for years, and reviewing medical records, this is very common, and hardship from financial standpoint is linked to underdosing more than anything,” Fletcher says.

“As coinsurance amounts increase and deductibles skyrocket, patients are trying to make their medications last longer, which will give them the ability to stretch their dollar, but as a result, they don’t fully feel the effects of the prescribed medication set forth by the physician. So that can really make a difference in the overall health picture when your physician is trying to bill that higher level of service,” Fletcher says.

Code Underdosing with these Steps

Step 1: While you want to note the fact that underdosing is happening, first you need to record the initial issue. “Report the medical condition. ICD-10 is pretty clear 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 a reduction in dose, code the condition first,” Fletcher says.

Step 2: Delve into the patient’s clinical record (or a conversation with the physician) to figure out the specific medication and then look to your ICD-10-CM book. “Identify or specify the underutilized drug. To complete these steps, go to Chapter 19 in your ICD-10 book and you pick a code from the categories T36 to T50 [Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances],” Fletcher says.

Hint: “For underdosing, your fifth or sixth character will always be a 6, so the position of the 6 varies by code, so be sure to check the index and the tabular list to confirm your code choice,” Fletcher says.

Step 3: Head to the end of the alphabet to find the codes you need. “To report underdosing, you will choose a code either from noncompliance, Z91.12-Z91.14, a new section in 2018, or complication of care, Y63.6-Y63.9, and that just explains a little bit about how it relates to medical care,” Fletcher says.

“Z codes explain the reason behind the patient’s noncompliance, and the codes are broken into two different categories: intentional and unintentional. So, remember, medical record documentation is really the key here to substantiate patients noncompliant with taking their medication,” she adds.

Here are some noncompliant code options:

• 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
• 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.

Note: The ICD-10-CM book added a new section in 2018 that became effective Oct. 1, 2018: Z91.14 plus a sixth character [Patient’s other noncompliance with medication regimen], which lacks the words “intentional” or “unintentional,” Fletcher says.

Top tip: The Y codes, which relate to medical care and not patient noncompliance, are not used very often, Fletcher says. Here are some codes that may apply to your patient’s situation:

• 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.

Bottom line: Figuring out that underdosing is happening and then documenting it effectively can be crucial to bolstering your success in getting paid for patient visits. “When I audit, I see [underdosing] in the narrative but I don’t see it from a coding perspective, and that’s huge if the patient is coming in more frequently and you want to get your encounters paid,” Fletcher says.