Wiki What is needed for 2021 MDM drug toxicity documentation

LauraNewYork

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Hi all,
I code EMs for a hematology/oncology practice. In the Risk column of the 2021 MDM is the example of drug therapy requiring intensive monitoring for toxicity. This is a High Risk. A lot of our patients are on chemotherapy and/or immunotherapy drugs many of which are cytotoxic, but I honestly don't know if all of these drugs fit this description.

I'm looking for some input. Should I have my providers include in the documentation that the drug(s) "have a high level of toxicity" or some related wording?
Laura
 
Hello Laura,

This is from the AAPC https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx

Drug therapy requiring intensive monitoring for toxicity is in the 2021 CPT® MDM table as an example of high risk of morbidity from additional diagnostic testing or treatment. To be sure the case you’re coding qualifies as intensive monitoring for toxicity, review these conditions listed in the guidelines:

The drug can cause serious morbidity or death.
Monitoring assesses adverse effects, not therapeutic efficacy.
The type of monitoring used should be the generally accepted kind for that agent, although patient-specific monitoring may be appropriate, too.
Long-term or short-term monitoring is OK.
Long-term monitoring occurs at least quarterly.
Lab, imaging, and physiologic tests are possible monitoring methods. History and exam are not.
Monitoring affects MDM level when the provider considers the monitoring as part of patient management.
An example of drug therapy requiring intensive monitoring for toxicity is testing for cytopenia (reduction in the number of mature blood cells) between antineoplastic agent dose cycles.

I hope this helps!

Theresa
 
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