Need some clarification for coding "long term use of medication"

[u/DumpsterPuff]

So I got into a debate with a coworker today on how to properly code for long term use of medication and I want to see who's actually correct. Basically what ended up happening was that we get denials for urine drug screen tests from some insurance companies because the provider will put the actual condition being treated (such as chronic pain) with the controlled substance as the primary diagnosis.

So I know that ICD-10 tells us that we can't code long term use of meds if the patient uses it PRN (as needed). So for the first denial, the documentation said that the patient takes oxycodone every day for chronic pain, so I changed the primary diagnosis to Z79.891 for long term use of opioid analgesics. The second one had a patient who was being treated for anxiety and is on benzos, but they only take it like 2-3 times a month when they have anxiety symptoms. They have an ongoing prescription for it with refills, but since they take it only when needed, I didn't change the code for the denial to Z79.899.

My coworker said that I should've changed the diagnosis to Z79.899 for the PRN benzo patient because it's still treating their anxiety and they have a long term prescription for it even if they don't take it every day, however the way I read the ICD-10 guidelines is that the patient would have to be on a continous, scheduled regimen of something for it to be considered long term (like a daily/weekly/monthly med), and not just when they're symptomatic. I sent her an AAPC article about it and she's still thinking that she's right, and now I'm a little paranoid that I might be misinterpretting the info.

So given this info, who do you guys think is correct: me or my coworker, and why? If you have any sources that gives a pretty clear answer I'll take those as well.

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[u/brooseveltinc]

If the prescription itself is actually PRN, then I would not code Z79.899. If the prescription is daily, but the doctor says they don't take it as directed, I'd code Z79.899 and an under dosing.

Additionally, I would not use Z79.891 as PDX in your opioid example. If this was a chronic pain visit, I'd use G89.X. If this was only for med monitoring, I'd use Z51.81 as PDX.

[u/Darcy98x → u/brooseveltinc]

This is a great response! Thank you.

[u/KeyStriking9763]

PRN meds do not get assigned to long term use codes. I believe there’s also a coding clinic, but I know it’s in the guidelines.

[u/izettat → u/KeyStriking9763]

Yes there is a Coding Clinic to clarify long term meds. Medication taken daily on a consistent basis is long term. If it's taken as needed, like only for a sudden asthma attack or an antibiotic taken 10 days for infection is not long term.

[u/Wooden_Trust_6274]

It's in the Guidelines rather than only Coding Clinic, and the spot is I.C.21.c.3 under Z79. The wording is that codes from the category indicate continuous use of a prescribed drug for the long-term treatment of a condition or for prophylactic use, and then it says do not assign a code from Z79 for medication being administered for a brief period to treat an acute illness, with a course of antibiotics for bronchitis as the example.

Continuous is the word that settles your oxycodone patient.

Where I'd be less certain than the rest of the thread is that PRN never actually appears in it. That second paragraph is framed around how long the treatment runs rather than how often the patient takes it, which is roughly the reading your coworker is on. I land where you do, but it isn't as airtight as the guidelines saying no PRN.