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Documentation of V58.69

  1. #1
    Default Documentation of V58.69
    Clearnace Sale
    What documentation would you expect to see when using V58.69 - Long-term (current) use of other medications? Would you accept documentation of a lengthy list of medications? Or would you expect to see the length of time that the patients were on the medications?

  2. Default
    I would seem to think there would have to be time documented. However, I have personally never seen a note where they didn't have it. For example, patient has been on prednisone for 6 months.... patient has been on Coumadin for two years... etc. I know those do not fall in the V58.69 but they are still basically the same codes, just more specific 5th digits. I hope that made sense.

  3. #3
    Thank you very much.

  4. #4
    Overland Park, KS
    Per Coding Clinic 4th Quarter 2002, There is no definition or time frame for long term. If a patient receives a drug on a regular basis and has multiple refills available for a prescription then it is appropriate to document long-term drug use. This documentation is at the discretion of the health care provider.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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