Your coding questions answered.
Q: When auditing MDM, is there a list of drugs that are considered “drug therapy requiring intensive monitoring for toxicity?”
A: CMS itself has not provided such a list for use with the 1995 or 1997 guidelines. This question is answered from those guidelines, but the end of the Q&A discusses the 2021 CPT changes.
Palmetto Medicare has a list of drugs requiring intensive monitoring.
This doesn’t mean other payers will follow this list. Many of the drugs on this list are given to patients chronically, as outpatients, and are not being monitored intensively.
Let’s use bronchodilators as an example. A patient with acute COPD in the ED who is receiving bronchodilators might qualify. A patient on chronic maintenance of the same class of drugs as an outpatient will not qualify.
When deciding whether to assign high risk, both the drug and the monitoring need to qualify. Doing bi-weekly lab or monthly lab tests, or following in the office every three months is not intensive monitoring.
For some of the medications, the initiation of the treatment may require frequent lab tests, phone calls and office visits. As the patient stabilizes, the frequency of lab tests, calls and visits will decrease. There is no definitive citation to guide a coder or clinician in either the list of drugs or what qualifies as “frequent monitoring.”
In 2021, CPT is revising the definitions for new and established patients, 99202–99215. (99201 will be deleted in 2021.) As part of the revised content that we’ll see in our CPT book in 2021, the AMA has defined drug therapy with intensive monitoring. You are not required to start using the 2021 definition now, but it is specific and clear, and your group could implement it, if desired.
From the AMA document, describing E/M changes 2021:
“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 less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does 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.”
This definition reflects the technical corrections issued by the AMA in March, 2021 and is the definition in the 2022 book.
Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.