MDS Alert
To Code Or Not To Code An Antidepressant Or Med-Related Dx
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Question: Do you code an antidepressant in O4 if it's ordered as a sleep aid or for pain management rather than for depression? Would physician documentation of a diagnosis as the reason for a resident taking a particular medication suffice for coding that diagnosis on the MDS? Answer: Code medications based on their pharmacological classification, not how the medication is used, advises Marilyn Mines, RN, RAC-CT, BC. (Refer to 3-180, clarification in the RAI manual.) While the RAI does not clarify what is considered to be physician documentation, a diagnosis to support a specific medication use would constitute documentation, adds Mines, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.
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