Vancomycin and High Risk MDM

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I'm curious if IV Vancomycin would generally be classified under "Drug therapy requiring intensive monitoring for toxicity" in the table of risk? From what I've read in trying to do some research, trough levels are monitored for concentration of the drug in the patient's system for efficacy purposes and to avoid development of resistance (for example a patient with MRSA infection), but not necessarily for 'toxicity'. The exception to this would be patients on aggressive dosing or patients with impaired or unstable renal function, the articles I've read say that these patients should be monitored more closely. I feel like this could go either way and that in some cases (ex. an otherwise healthy patient without renal impairment) it would be a stretch to classify it as high risk. Would you classify IV Vancomycin as high risk?
 

fwnewbie

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As a nurse we were taught Vancomycin is a toxic drug and extra labs were monitored. I don't know how the coding world views it.
 

thomas7331

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My opinion on this as a coder, and which I've expressed here on the forum in the past, is that the risk should be based on the provider's documentation and not on what particular drug is given. Remember that in assigning MDM, we are assigning a level to the documentation and not to our own understanding of the patient's condition based on outside sources. If the provider's documentation of their assessment and treatment plan reflects a concern for the risk to the patient of this drug, or shows that they are initiating orders to mitigate this risk, then it could warrant high risk. But if the documentation simply shows that the patient is receiving this drug, I don't believe that this, in and of itself, is sufficient to make that determination.
 
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My opinion on this as a coder, and which I've expressed here on the forum in the past, is that the risk should be based on the provider's documentation and not on what particular drug is given. Remember that in assigning MDM, we are assigning a level to the documentation and not to our own understanding of the patient's condition based on outside sources. If the provider's documentation of their assessment and treatment plan reflects a concern for the risk to the patient of this drug, or shows that they are initiating orders to mitigate this risk, then it could warrant high risk. But if the documentation simply shows that the patient is receiving this drug, I don't believe that this, in and of itself, is sufficient to make that determination.
Thank you, good point. I was given the impression that if the patient is on this drug then it is automatically high risk because they are doing labs. But I was reading up on why they monitor the levels, to see if this particular drug was considered highly toxic or anything. The provider is ordering labs for trough levels, I was waffling on if this is just standard for dosing determination vs. monitoring for toxicity because it's not clear to me from what is documented that the provider considers the med a toxicity risk. Unless I'm being too literal and it's one and the same- they are monitoring levels to determine dosage and prevent toxicity?
 

Pathos

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My opinion on this as a coder, and which I've expressed here on the forum in the past, is that the risk should be based on the provider's documentation and not on what particular drug is given. Remember that in assigning MDM, we are assigning a level to the documentation and not to our own understanding of the patient's condition based on outside sources. If the provider's documentation of their assessment and treatment plan reflects a concern for the risk to the patient of this drug, or shows that they are initiating orders to mitigate this risk, then it could warrant high risk. But if the documentation simply shows that the patient is receiving this drug, I don't believe that this, in and of itself, is sufficient to make that determination.
I agree with Thomas. As with everything else related to coding, documentation is king. Even if you have a clinical background or knowledge, be careful and don't assume. At the end of the day, if the documentation doesn't support a code, then you shouldn't code it or assign a certain unsupported level of Risk. When it comes to "Drug monitoring for toxicity" as part of the Risk Management Options, as stated above, remember that the drug needs to be monitored for actual toxicity which drives up the Risk for the patient. Some clinics have policies for this or that, however that's a risk those clinics choose to take. I would educate your providers on "precise" and "actual" documentation (only document what you're doing and don't document just to get a certain level), and perhaps guide them (without leading) on what that particular section in Risk means. Clinic policies will not help when they get audited by CMS or OIG, only appropriate documentation and coding will.

Hope this helps! :)
 
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I agree with Thomas. As with everything else related to coding, documentation is king. Even if you have a clinical background or knowledge, be careful and don't assume. At the end of the day, if the documentation doesn't support a code, then you shouldn't code it or assign a certain unsupported level of Risk. When it comes to "Drug monitoring for toxicity" as part of the Risk Management Options, as stated above, remember that the drug needs to be monitored for actual toxicity which drives up the Risk for the patient. Some clinics have policies for this or that, however that's a risk those clinics choose to take. I would educate your providers on "precise" and "actual" documentation (only document what you're doing and don't document just to get a certain level), and perhaps guide them (without leading) on what that particular section in Risk means. Clinic policies will not help when they get audited by CMS or OIG, only appropriate documentation and coding will.

Hope this helps! :)
This is helpful, thank you. I'm not clearly seeing from the documentation that it is being monitored for toxicity. There are phrases like 'continue vancomycin therapy, continue to monitor trough' or 'continue vancomycin, would increase to 1g IV Q8H based on troughs' so to me this sounds like its for dosing vs. toxicity which would not allow me to use it to assign a high level of risk.
 
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