Inpatient Facility Coding & Compliance Alert

Draw on an impeccable strategy for reimbursement with the 4 A’s.

Are you aware of the specific documentation requirements for opioid pain management? Read on to find out how making precise notes of certain aspects can help you maintain high-quality care.

Be Guided by the 4 A’s Ace Strategy

Remember, pain relief should be the primary focus of the provider imparting opioid therapy at each visit. Therefore, try to address all the domains of the pain the patient feels, and document them at each visit.

• Analgesia achieved: Remember to monitor the pain levels pre- and post-treatment, to gauge the effectiveness of your therapy. You can use the pain scales available, and ask the patient to maintain a log of pain levels through the various treatments. This objectivity will guide your therapy goals and decisions.

• Activities the patient can do: This refers to all those activities that the patient requires or desires to be capable of doing to maintain a productive life and live up to the social, work, and family roles expected of him. Patient goals might include the ability to work or to be active in one’s home. The patient helps you choose the functional activities that are vital to him. From a baseline on the current functional status of the patient (which could be because of pain or inhibition), you can then structure a plan with improving those activities as one of the treatment goals.

• Adverse effects: As the old adage goes, “Above all, do no harm.” You may also need to track if the medications are causing any side effects. This domain is particularly important, as opioids can cause constipation, sedation, respiratory depression, and other adverse effects that can lead to dangerous complications.

• Aberrant drug-related behaviors: Is your patient taking too many pills? You must consistently assess and document any unusual behaviors in all chronic pain patients. Tests (such as urine drug screenings) can provide evidence for or against diversion and use of other substances of abuse and a review of the state’s controlled substance database. Periodic use of objective and/or subjective validated screening tools can help stratify patient risk assessment.

Chime in With Medical Necessity Guidelines

Make sure you are aware of the payer’s policies regarding monitoring chronic opioid therapy (COT) and medical necessity requirements. 

“When healthcare providers contract with third-party payers, links to information about payment policies is a part of the contractual process” explains Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. He further adds, “If the third-party payer has rules regarding COT, they should be readily available.”

For example, Palmetto’s “Controlled Substance Monitoring and Drugs of Abuse Testing” states that, “Ongoing testing may be medically reasonable and necessary based on the patient history, clinical assessment, including medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect or behavioral pattern.” 

You would need to do a complete clinical assessment of the patient’s risk potential for abuse and diversion using a validated risk assessment interview or questionnaire. Keep these tips in mind when evaluating the patient:

• The assessment should include the patient’s response to prescribed medications and any medication side effects.

• Perform random UDT (urine drug testing) at random intervals, in order to properly monitor a patient. 

• When assessing patients that have specific symptoms of medication aberrant behavior, remember to evaluate them in accordance with the payer’s guidance for monitoring patient adherence and compliance during active treatment (<90 days) for substance use or dependence.

Finish Off With Impeccable Diagnosis Codes

Include appropriate ICD-9 codes in your claim that support medical necessity for COT. Palmetto offers the following guidance: 

• For monitoring of a patient compliance in a drug treatment program, use ICD-9-CM code V71.09 (Observation of other suspected mental condition) as the primary diagnosis and the specific drug dependence diagnosis as the secondary diagnosis. Examples of possible secondary diagnoses might include 304.21 (Cocaine dependence, continuous use), 304.32 (Cannabis dependence, episodic use), or 304.71 (Combinations of opioid type drug with any other drug dependence, continuous use). 

• For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence, suspected of abusing other illicit drugs, use code V58.69 (Long-term [current] use of other medications).

Remember that you should select the most appropriate diagnosis code. And, remember that labs are not to pre-populate requisition forms with a diagnosis. LCDs will prohibit “hard coding” a single ICD-9 code for every lab requisition, such as V58.83 (Encounter for therapeutic drug monitoring), rather than reporting a diagnosis specific to the patient.