Coding Corner, a new section that will appear periodically in The Hospitalist, features common coding and/or billing issues hospitalists regularly face. If you have suggestions for upcoming coding issues you’d like addressed, email us at [email protected].
Case
A 64-year-old woman with a history of heart failure with reduced ejection fraction was admitted to the hospital with orthopnea and dyspnea on exertion for one week. You admitted her to the hospital for intravenous (IV) diuresis and you see her now on day three of her admission. She is diuresing adequately on IV Lasix 40 mg twice a day, but after examination, you feel like she needs another one to two days of IV diuresis. You order another basic metabolic panel to monitor her serum creatinine. You review her basic metabolic panel from the morning labs, speak to the patient’s daughter, and get some more history about the reason for this exacerbation.
Q: What level of billing does this qualify for?
A: This would qualify for level-3 (99233) billing. She would qualify for severe exacerbation of chronic illness by virtue of her being hospitalized (high level in complexity of problem addressed) and drug therapy needing intensive monitoring of labs for toxicity (high level for risk of complication). Even though the complexity of the data reviewed is moderate, she achieved high-level MDM, or medical decision making, in two out of three elements.
Tip
Always look at the medical decision making table when billing. A chronic illness that needs hospital admission for exacerbation is usually looked upon as a severe exacerbation, and IV diuretics are common medications that need intensive monitoring of labs for toxicity.
Dr. Mehta is the medical director and an assistant professor of medicine at the University of Cincinnati Medical Center in Cincinnati, and a member of The Hospitalist’s editorial board.
I was told by previous documentation specialist that this specific example would not qualify for monitoring for toxicity. This potential complication is not a toxic build up of diuretic, rather it is a side effect of the medication (volume depletion or hypokalemia). Was that not correct?
I also think this is a loose interpretation of the word “toxicity” – but I see it interpreted this way over and over. By this interpretation, checking glucose levels for any patient on insulin is “monitoring for toxicity”. Whether you use the word toxicity or not, I think you could state something like “Continue IV diuresis and intensive hospital monitoring to prevent deleterious effects of treatment”. I don’t think any coder could argue with that.
The AMA specially addresses this in the guidelines. Does the very last sentence support the case example used above? The AMA talks about monitoring electrolytes and renal function. Infrequent monitoring is a no, where maybe inpatient is a yes? “Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. The monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. An example may be monitoring for cytopenia in the use of an antineoplastic agent between dose cycles. Examples of monitoring that do not qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic effect (unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the threshold.”
Thank you for all these comments. Yes, I do think monitoring for electrolytes and creatinine for IV diuretics would qualify for “toxicity” from this medication in the same way that cytopenias could happen due to anti-neoplastic agents. Insulin is a different predicament but @LindaDuckworth has mentioned it well in her AMA guidance statement.