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Coding Corner Tips: Underdosing
Coding Corner copy

Underdosing

Per Coding Clinic, First Quarter 2024: Underdosing when a PRN medication is not taken

Example:

Documentation states: A patient presents to the ED with shortness of breath due to an exacerbation of asthma. The patient did not take his PRN medication, albuterol, because he lost his inhaler. Is it appropriate to assign a code for underdosing when a PRN medication, such as albuterol is not taken?

It is not appropriate to assign a code for underdosing when a PRN medication is not taken. Assign code Z91.198, Patient’s noncompliance with other medical treatment and regimen for other reason. Albuterol may help with the symptoms of asthma; however, it is not a maintenance medication, and the asthma exacerbation was not caused by the patient not taking albuterol.

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e4health is dedicated to elevating the business of healthcare. We are committed to offering support and the most current information and updates to collaborate with coding and CDI professionals to realize their fullest potential. We enthusiastically seek opportunities to develop ourselves and each other. We understand that knowledge is the key to success for our clients navigating the ever-changing health information management landscape.

 

The information and opinions presented here are based on the experience, training, and interpretation of e4health. Although the information has been researched and reviewed for accuracy, e4health does not accept any responsibility or liability regarding errors, omissions, misuse, or misinterpretation. This information is intended as a guide; it should not be considered a legal/consulting opinion or advice.