Wiki Risk Table - Where To Count Fentanyl Patch?

[adwood68]

Where should I count Fentanyl Patch on the table of risk? When you look at the high category for management options it list parenteral controlled substances. A patch is parenteral because it is not given orally or rectally, an Fentanyl is definitely a controlled substance, so I was leaning towards counting it there. But as a wise colleague of mine pointed out patients are sent home with Fentanyl patches so how high risk are they really. Would love to hear your comments on this question. I tried to see if any of the MACs had answered this question but I couldn't find any. Thank you in advance.

 

[SharonCollachi]

How high risk are they?? Not that it matters, it definitely counts as a parenteral controlled substance, but the fact that people who are opioid-naive die from exposure to the patch means yes, it really is high risk. The FDA has included fentanyl patches on a list of items that should be flushed down the toilet, despite the risk to the environment, because a child or pet finding them in the trash puts that child or pet at a high risk of death.

You're not evaluating the appropriateness of an category in the risk table. The category is already there. Fentanyl patches are parenteral. Fentanyl is a controlled substance. Therefore, it is a parenteral controlled substance.

 

[thomas7331]

I would disagree that this is high risk. Although parental does mean outside of the digestive tract, that term is normally used to refer to drugs that require sterile preparation and which are administered by injection. The topical or transdermal route is clearly a lower risk and I'd agree with your colleague here. Unless the provider has stated something in the record to specially suggest that this form of treatment is posing an elevated risk to the patient or requires close monitoring, I do not believe the high risk assignment would be supported.

I'd just remind again of the guidelines on the use of the risk table which state that "because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk." The table is meant as a guideline only - the fact that something may appear in one particular part of the table does not mean that it always applies to every patient and every encounter. It is up to the provider to document their assessment of the risk to the patient of a particular condition or treatment.

 

[Tonyj]

I have to respectfully disagree with Thomas7331 response.
Fentanyl, no matter how it is administered, carries the FDA's black box warning.
The black box warning is the strongest warning that the FDA requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects.
I would definitely classify this as high risk.

 

[thomas7331]

I have to respectfully disagree with Thomas7331 response.
Fentanyl, no matter how it is administered, carries the FDA's black box warning.
The black box warning is the strongest warning that the FDA requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects.
I would definitely classify this as high risk.

Thank you Tonyj, I understand what you're saying here and don't disagree with the risks associated with this drug. However, there are many other commonly prescribed drugs that carry the same black box warning (e.g. Cipro, Zoloft, Synthroid), but that does not warrant automatic assignment of high risk to an E&M level. The important point is that E&M guidelines always direct you to the provider's documentation, not to any outside source or list. Again, the table of risk is a guideline and a tool for assessing the level of risk as documented in the patient's record.

I don't say this just as a matter of personal opinion, but based on my experience with many first- and second-level appeals of CMS and commercial payer downgrades of E&M code levels where high-risk drugs are part of the treatment plan. The auditors in these organizations are very firm in holding that the appearance of a particular drug's name in a note by itself is not sufficient to warrant high risk if it is not accompanied by provider documentation that also reflects their assessment of the associated level of risk to the particular patient and/or encounter.

Of course, payers and their rules and practices vary greatly, so different coders and auditors may have had different experiences. Ultimately, no one can give you an yes or no answer on something like this. We all need to consider our providers' documentation and follow our own judgment on what is best, and be prepared to defend our decisions. After all, if there was always a 'right' answer, then computers could be programmed to code charts and there wouldn't be a need for a coders at all.

 

[Tonyj]

Thank you Tonyj, I understand what you're saying here and don't disagree with the risks associated with this drug. However, there are many other commonly prescribed drugs that carry the same black box warning (e.g. Cipro, Zoloft, Synthroid), but that does not warrant automatic assignment of high risk to an E&M level. The important point is that E&M guidelines always direct you to the provider's documentation, not to any outside source or list. Again, the table of risk is a guideline and a tool for assessing the level of risk as documented in the patient's record.

I don't say this just as a matter of personal opinion, but based on my experience with many first- and second-level appeals of CMS and commercial payer downgrades of E&M code levels where high-risk drugs are part of the treatment plan. The auditors in these organizations are very firm in holding that the appearance of a particular drug's name in a note by itself is not sufficient to warrant high risk if it is not accompanied by provider documentation that also reflects their assessment of the associated level of risk to the particular patient and/or encounter.

Of course, payers and their rules and practices vary greatly, so different coders and auditors may have had different experiences. Ultimately, no one can give you an yes or no answer on something like this. We all need to consider our providers' documentation and follow our own judgment on what is best, and be prepared to defend our decisions. After all, if there was always a 'right' answer, then computers could be programmed to code charts and there wouldn't be a need for a coders at all.

Thank you for the response!
Your experience and knowledge in this area is of the utmost value.
I have not had to dispute this particular area as I never had a denial for high risk even though I've billed many drugs accordingly. I appreciate and respect your advice.
Best
Tonyj