Wiki Documentation of V58.69

[shannfd]

What documentation would you expect to see when using V58.69 - Long-term (current) use of other medications? Would you accept documentation of a lengthy list of medications? Or would you expect to see the length of time that the patients were on the medications?

 

[eadun2000]

I would seem to think there would have to be time documented. However, I have personally never seen a note where they didn't have it. For example, patient has been on prednisone for 6 months.... patient has been on Coumadin for two years... etc. I know those do not fall in the V58.69 but they are still basically the same codes, just more specific 5th digits. I hope that made sense.

 

[shannfd]

Thank you very much.

 

[dballard2004]

Per Coding Clinic 4th Quarter 2002, There is no definition or time frame for long term. If a patient receives a drug on a regular basis and has multiple refills available for a prescription then it is appropriate to document long-term drug use. This documentation is at the discretion of the health care provider.