Written by Nicole Benson, BA, CPC, CPMA, COSC
Over the years, the AMA and payors have continued to clarify and refine drug management as a part of the medical decision-making risk. In the 2023 guidelines, within the medical complexity tables, column three, there are separate areas addressing prescription drug management (categorized as moderate risk), drug therapy requiring intensive monitoring for toxicity, and parenteral controlled substance (both categorized as high risk). So, what is the difference between these drug managements and when is the intensive drug therapy monitoring supported? Here are some definitions and tips from the AMA and industry research over these risk categories.
Prescription drug management is based on documented evidence that the provider has evaluated the patient's medications as part of a service versus simply listing medications or refills. This may be a prescription being considered, written, discontinued, or the decision to maintain a current medication/dosage. Documentation should include evidence over these medication considerations, as well as appropriateness and any interaction concerns. Prescription drug management differs from "drug therapy requiring intensive monitoring for toxicity.” Here is the defining list of the AMA 2021 Technical Corrections that can be found in the current year CPT E/M guidelines for meeting this high-risk category.
• 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 drug 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
CMS has not provided a list of high-risk drugs that would typically require intensive monitoring, yet several Medicare contractors, including Palmetto GBA, has published the AMA guidelines and a limited list of higher risk medications. One such example found is the 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. A non-qualifying example would be monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold of intensive monitoring defined above.
A parenteral controlled substance is given by a route other than the alimentary canal or oral, and may include subcutaneous, intramuscular, intravenous, or intrathecal administered medications and is categorized under the schedule of controlled drugs. While the initiation of parenteral controlled medications may represent high risk, once they have reached a therapeutic effect and/or stabilized, they may not continue to represent high risk in complexity as cited by Dr. Holman during the 2022 AMA Symposium. Some parenteral administration may even be safer than oral medications in terms of ongoing opiate use. It is always important to specify in the documentation the overall risk of any medications, considerations, and monitoring, as the ownness is up to the provider to support and define these drug management areas in terms of the risk complexity.