Wiki Non compliance underdosing

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Pt comes in with headache pt also mentions they have hyperlipidemia and have not been taking meds as prescribed they take them differently. they also have meds for asthma, bipolar, epilepsy
meds listed are specific to the asthma, bipolar and epilepsy And they are not taking those at all.

pt is treated for Headache and discharged.

would I code the noncompliance of Medication for the asthma, bipolar and epilepsy and underdosing of the meds for hyperlipidemia seeing how they weren’t treated ? Would I code the conditions with the underdosing and noncompliance or just the z codes themselves?
thank you
 
Pt comes in with headache pt also mentions they have hyperlipidemia and have not been taking meds as prescribed they take them differently. they also have meds for asthma, bipolar, epilepsy
meds listed are specific to the asthma, bipolar and epilepsy And they are not taking those at all.

pt is treated for Headache and discharged.

would I code the noncompliance of Medication for the asthma, bipolar and epilepsy and underdosing of the meds for hyperlipidemia seeing how they weren’t treated ? Would I code the conditions with the underdosing and noncompliance or just the z codes themselves?
thank you
In this instance, document only reports that the patient is taking the prescribed medication differently; that is not equivalent to Under dosing. You need to review the document properly to identify any detail of underdosing or query the physician. Underdosing coding guideline mandates that the condition for which patient was prescribed medication should be reported as PDx following by underdosing codes (T series), followed by Z91.12 series for "Patient's non-compliance with medication due to financial constraints/ other reasons".
Hope this helps. :)
 
ajeet.dey@genpact.com I agree with what you said above. I have a different scenario pt comes for cough, fever, discolored phlegm and the HPI mentions pt also states she is not taking her Lexapro. PMH anxiety depression.
Final URI no more mention of the Lexapro do I still have to code a T and Z code even though the pt is not being treated for anxiety/depression? If yes I will also list the anxiety and depression?
Thank you
 
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