When we see a patient being monitored for drug toxicity due to being on methotrexate, our physician will occasionally recommend changes in medication dosages to the prescribing physician based on diagnostic tests results.

Can you tell me if this meets high complexity for the risk component and a level 5 evaluation and management (E/M) code?

Answer:

This would not qualify as a level 5 E/M code. To meet the American Medical Association definition of a high problem (acute or chronic illness that poses a threat to body function), it requires treatment in the near term (e.g., 24 hrs.) or the patient will go blind or have significant visual loss. High risk would be emergency major surgery or hospitalization.

Although high complexity of risk includes “Drug therapy requiring intensive monitoring for toxicity” monitoring for side effects of a medication managed by another provider does not meet this definition. Additionally, the intensive monitoring has specific requirements and may be short-term or long-term, and in the latter case it must be provided at least quarterly. The monitoring can involve labs, imaging, or physiologic tests, but monitoring by history or exam wouldn’t be sufficient.

Overall medical decision-making requires that two of the three components (problem, data, and risk) meet or exceed the same level of complexity.