Coding and Billing

Coding for Long-Term Medication Use

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD
ROB Professional Editors

Sept. 6, 2017

Plaquenil was originally used to treat malaria. Plaquenil is used today to treat inflammatory disease. Diseases treated with Plaquenil today are Lupus, Sjögren’s syndrome and rheumatoid arthritis. These diseases occur when the immune system attacks the patient’s own body. Plaquenil works by lowering the immune system’s response.

Understanding how to code for a patient’s long-term use of Plaquenil will give you a template for coding for other kinds of long-term medications.

Long-term use of Plaquenil can harm the retina. This is especially true of people who meet any of these criteria:

• Taking Plaquenil for five, or more, years
• Taking Plaquenil at higher doses than recommended
• Already has retinal disease
• Already has kidney or liver disease
• Over 60-years-old
• Has lost a lot of weight while taking Plaquenil
• High body mass index
• Cumulative dosage of > 1,000 g Plaquenil

The exam protocol for patients taking Plaquenil is:
Screening Schedule: A baseline fundus examination should be performed to rule out preexisting maculopathy. Begin annual screening after five years for patients on acceptable doses and without major risk factors.

Obviously, if adverse effects occur, Plaquenil treatment stops immediately and the protocol changes.

The question we want to address today is: how do you code for patients taking Plaquenil?

The general outline we are going to follow in our coding is:

• Primary condition
• Long-term medication
• Adverse effects

Primary Condition
The first diagnosis is for the specific condition for which the doctor prescribed the Plaquenil. Rheumatoid arthritis is often the condition triggering the need for Plaquenil. Blue Cross Blue Shield of Michigan created a helpful Rheumatology ICD-10-CM Coding Tip Sheet that you can view HERE.

One of the advantages of having all of our electronic medical records linked together is that we will be able to pull up the specific diagnosis from the doctor who prescribed Plaquenil for the patient in our chair. Until we have, and are using that technology, we need to do it the old fashioned way by calling the prescribing doctor to identify the specific diagnosis used so that we are all using the same diagnosis in our coding.

For the purposes of our example today, let’s use the diagnosis of “rheumatoid arthritis without rheumatoid factor, vertebrae.” This codes in the ICD-10-CM system as M06.08.

Long-Term Medication
Next, we need to code for the Plaquenil. There is not yet a specific code for Plaquenil, so we must choose “Long term (current) use of other drug therapy,” which is Z79.899. (There are specific Z codes for anticoagulants, insulin, systemic steroids, aspirin, and many more so make sure you use the proper code.)

Adverse Effects
If Plaquenil has contributed to a maculopathy, then you must code for that as well. Your choices for this are based on whether this is an initial encounter, a subsequent encounter, or is this is a sequela? The specific codes for those situations are:

T37.2x5A: Adverse effect of anti-malarials and drugs acting on other blood protozoa, initial encounter.
T37.2x5D: Adverse effect of anti-malarials and drugs acting on other blood protozoa, subsequent encounter.
T37.2x5S: Adverse effect of anti-malarials and drugs acting on other blood protozoa, sequela.

Now that you know how to code for Plaquenil, you can use this example as your model for patients taking other long-term medications.

 


Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD, are the professional editors of Review Optometric Business. To reach them: mwright@pathways-o.com

 

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