Revenue Cycle Insider

Question: According to the Risk of Complications element of the CPT^® medical decision making (MDM) table, “drug therapy requiring intensive monitoring for toxicity” is listed as a high risk of morbidity. Does that mean any toxic drug administration automatically rises to that level?

Colorado Subscriber

Answer: The definitions that accompany the CPT^® Evaluation and Management (E/M) Services Guidelines specify that only a drug that is “a therapeutic agent that has the potential to cause serious morbidity or death” and “that requires intensive monitoring” can rise to a high risk of morbidity in the MDM table. So, “an example may be monitoring for cytopenia in the use of an antineoplastic agent between dose cycles,” CPT^Ò clarifies, adding that “examples of monitoring that do 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.”

Palmetto GBA, the Part B Medicare Administrative Contractor (MAC), elaborates further:

• Drugs that are not high risk are “drugs with a well-defined clinical response and a high therapeutic index (i.e., low toxicity),” because, for these drugs, “intensive therapeutic drug monitoring is not necessary. Additionally, for drugs treating acute or short-term conditions, “there is no advantage to monitoring drug levels,” so they cannot be considered high risk. So, too, are drugs that treat “chronic disorders … if the desired response can be readily assessed by a noninvasive technique, such as blood pressure monitoring [and] serial drug level monitoring is not medically necessary.”
• Drugs that are high risk include “administration of cytotoxic chemotherapy… when monitoring of blood cell counts is used as a surrogate for toxicity,” per Palmetto GBA. In other words, “drugs that have a narrow therapeutic window and a low therapeutic index may exhibit toxicity at concentrations close to the upper limit of the therapeutic range and may require intensive clinical monitoring.”

For oncology, that means you can assign a high MDM risk element when monitoring all cytotoxic agents, including ankylating agents, antimetabolites, antimicrotubule agents (mitotic inhibitors), topoisomerase inhibitors (I and II), and miscellaneous antineoplastics such as the ones on this list provided by BC Cancer.

But before you assign an overall high level of MDM to an office/outpatient E/M encounter where your provider is monitoring possible drug toxicity in a patient, remember to:

• Provide documentation which, in Palmetto’s words, shows monitoring “of drug levels obtained at appropriate intervals, or, in CPT^®’s words, demonstrates “that which is generally accepted practice for the agent but may be patient-specific in some cases.”
• Document another MDM element at the high level, as “to qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded,” per CPT^Ò guidelines.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC