Q&A: Querying for a condition based on administered medications

Q: Can the physician be queried as to why the patient is taking methadone or suboxone? If yes, how would it be presented?

A: Yes, the physician can be queried as to why the patient is taking methadone or suboxone. There should be a diagnosis for every medication taken. The definition for “other” or “secondary” diagnosis is a condition (either present on admission or developing subsequently) per the Uniform Hospital Discharge Data Set (UHDDS) that requires:

• Clinical evaluation, or
• Therapeutic treatment, or
• Diagnostic procedures, or
• Increase nursing care and/or monitoring, or
• Extended length of stay

Only one of these criteria needs to be met. Medication meets the criteria of treatment and would be a reason to query a physician. Here’s an example for you:

Dear Doctor;

Mrs. Smith, a 68-year-old female, was admitted to the hospital as an inpatient on (date) for (principle diagnosis) with a past medical history of (what the H&P states). Per the medication list, she is taking (methadone or suboxone) the (route and dosage). Could you please clarify in your next progress note the medical diagnosis for which this patient is taking the above medication.

Thank you,

CDI Specialist

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.