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MDM Question - monitoring for toxicity

  1. #1
    Location
    Pottstown/Philadelphia
    Posts
    266
    Default MDM Question - monitoring for toxicity
    Exam Training Packages
    I wanted to know if anyone could give me a few examples of "Drug therapy requiring intensive monitoring for toxicity". Does IV Lasix quantify under moderate or high mdm?

  2. Default
    I worked in intensive care as a unit secretary for 10 yrs. The drugs that come to my mind as toxic, or the ones the doctors ran levels on most frequently were Digoxin/Lanoxin, Theophylline and Aminophylline and some psychiatric drugs.

  3. #3
    Location
    Pottstown/Philadelphia
    Posts
    266
    Default
    so here is the note why i wanted to know where to quantify "iv lasix". the dr is telling me that iv lasix should be marked under high risk for drug therapy inquiring monitoring for toxicity. What do you think?

    PLAN:
    IV LASIX NOW
    REPEAT CXR
    STOP ATIVAN - WILL RESUME AT HOME DOSE WHEN PT FULLY AWAKE
    CARDIOLOGY CONSULT
    MOVE TO TELE

    PROBLEM LIST:
    1) Urosepsis
    2) Sacral decubiti and possible cellulitis
    3) CHF
    4) DM2
    5) Anxiety
    6) Decrease in global functioning / failure to thrive
    7) Pain control/neuropathy
    8) A Fib

    SUBJECTIVE:
    PT NON-VERBAL. PER HUSBAND A LITTLE MORE AWAKE LAST NIGHT. NO EVIDENCE OF AGITATION OR PULLING AT IV AND FOLEY PER HUSBAND AND NURSING. MORE DYSPNEIC PER DTR.

    OBJECTIVE:
    Item Value Date Time
    Patient Temperature 98.3 degrees F 9/18/09 0800
    Temperature Source Axillary 9/18/09 0800
    Pulse Rate 72 bpm 9/18/09 0800
    Respiratory Rate 28 bpm H 9/18/09 0800
    Blood Pressure Assessment 158/68 9/18/09 0800
    Location Right Upper Arm
    Bedside Pulse Oximetry 93 % L 9/18/09 0015
    Sodium Level 143 mmol/L 9/17/09 0545
    Potassium Level 4.1 mmol/L 9/17/09 0545
    Chloride Level 109 mmol/L 9/17/09 0545
    Carbon Dioxide Level 26.7 mmol/L 9/17/09 0545
    Blood Urea Nitrogen 33 mg/dL H 9/17/09 0545
    Creatinine 0.95 mg/dL 9/17/09 0545
    Prothromb Time International Ratio 2.79 INR 9/18/09 0540
    Percent Meal Consumed Bites 9/18/09 0926
    Percent Meal Consumed 0% 9/17/09 1815
    Bedside Blood Glucose 98 mg/dl 9/17/09 2029
    Bedside Blood Glucose 114 mg/dl 9/18/09 0000
    Bedside Blood Glucose 146 mg/dl H 9/18/09 0600


    PHYSICAL EXAM:
    General: Mod resp distress using abdominal accessory muscles.
    Heart: Regular rate and rythym, no murmur, rub or gallop
    Lungs: clear to auscultation bilaterally without wheezes, rales or rhonci
    Abdomen: Soft, non-tender, nondistended, + bowel sounds
    Extremities: warm and dry without cyanosis, clubbing, 2+peripheral pulses, edema

  4. #4
    Location
    Pottstown/Philadelphia
    Posts
    266
    Default
    Oh, also...this is a subsequent visit for a hospitalist and he chose a 99233. I bumped him down one. Of course, he got very defensive. I just needed some clarification to see if I was truly incorrect due to the iv lasix.

  5. #5
    Default
    Your Medicare carrier/MAC may have published guidelines. My carrier, Palmetto GBA, has written a specific response in their FAQs responding to examples of medications they consider to be high risk: "Examples of drugs categorized as high risk are most chemotherapy drugs and certain cardiac drugs with narrow therapeutic ranges such as Amiodarone. If you look in a drug book, you will see that Amiodarone is listed as 'toxic', but drugs like Coumadin and Rocephin are not."

    A more comprehensive list of high-risk drugs is listed at this link:
    http://www.palmettogba.com/Palmetto/Providers.nsf/files/Drug_Therapy_Requiring_Intensive_Monitoring_for_To xicity.pdf/$FIle/Drug_Therapy_Requiring_Intensive_Monitoring_for_To xicity.pdf
    Jenny Berkshire, CPC, CEMC, CGIC

  6. #6
    Location
    St. Joseph County, Indiana
    Posts
    101
    Default
    I am looking for guidance on the "toxic" issue as well. I tend to focus on the term 'high risk' more than 'toxic".

    I work with pain management practices who have used Suboxone or Lidocaine infusions, etc. These medications are very effective but have a high risk of pt complications..such as your heart stopping..not just toxicity.

    Using this philosophy, I would argue on behalf of the physician. Lasix can be a high risk drug...even thought the risk isn't necessarily associated with toxicity.

    Don't loose sight of the real issue: the work and risk associated with providing a service.

    Brock Berta, CPC

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default Table of Risk measures Risk to PATIENT
    The table of risk is a tool to quantify the risk to the PATIENT (not to the doctor).

    You may not want to focus on the toxicity issue, but that is clearly the requirement per the table.

    That being said, I wish more carriers would define this - or even CMS. Because it is SOOOo open to interpretation.

    F Tessa Bartels, CPC, CEMC

  8. #8
    Location
    South Bend
    Posts
    23
    Default
    I think the key words are "intensive monitoring" in your original question. After starting this medication how often was it medically necessary to monitor the levels for possible toxicity?

    I think how you answer the question will answer your original posting.

    Sandy Goodknight, CPC, CPMA, CEMC
    Indiana

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