Primary Care Coding Alert

Question: We performed a nine-panel drug screen on a patient because the family physician believed that the patient wasn't taking his medication correctly. Which ICD-9 code should we report for this?

Tennessee Subscriber

Answer: Because the FP performed the drug screen to monitor the patient's therapeutic drug use, you should report V58.83 (Encounter for therapeutic drug monitoring). If the physician is managing long-term (current) prescription drug use (such as for Coumadin treatment), you should report an additional code in the V58.61-V58.69 series.

You should assign V15.81 (Noncompliance with medical treatment) as a secondary diagnosis if you're certain that the patient failed to take his prescribed medications.

If the FP merely suspects that the patient took his medication incorrectly and none of the above V codes are appropriate, you should report the ICD-9 code for the underlying condition. In this case, report the condition that required the prescription drug or the symptoms that prompted the drug screen. For example, if the patient complained of dizziness and a lack of coordination, you should report 780.4 (Dizziness and giddiness) and 781.3 (Lack of coordination).