Always appreciate these questions and discussion since I feel continually lost in the coding wilderness and generally frustrated with the vagueness of the MDM criteria and how, uh, let’s just say "malleable" they can be for those highly motivated to bill at a certain level. Agree with everyone above. I think (in the absence of billing on time) the vast majority of IV irons are a 4 at best, and I can only think of rare instances where they would approach a 5. Breaking down by MDM element:
Element 1: Problems Addressed
Out of all the criteria, element 1 always feels the most open to interpretation to me, but even so I’m not sure how a hemodynamically stable patient with iron deficiency anemia would quality as “high” here unless you take a very generous interpretation of “chronic illnesses with severe exacerbation.” OP raised the point of whether severe iron deficiency potentially causing long-term organ dysfunction would qualify… in my mind if it would then couldn’t you say that about nearly every medical problem (“If I don’t control this SBP of 152 with lisinopril this patient may die of ESRD in 20 years!” --> 5)? The only instance I could think of that may qualify is a patient with anemia at a level requiring transfusion and/or admission but is refusing both, and you’re just trying to stem the tide as best you can with IV iron. So not impossible to hit “high,” but for the majority of the referrals I see I think it’s pretty rare.
Element 2: Data Reviewed
For me, I’d rarely hit either category 2 (independent interpretation of a test) or category 3 (direct discussion with another provider) to hit “high” here. Nearly all the cases are just reviewing old records/labs and ordering new labs, so “moderate” at best, feels pretty straightforward.
Element 3: Risk
IV iron is not a high risk medication. AMA guidelines state “a drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.” That last line meaning, yea, we check Hgb and iron stores 1.5-3 months after we given IV iron, but that doesn’t quality as “intensive monitoring” since the purpose of those labs is to monitor the therapeutic effect, not for any toxic side-effect. Maybe if you’re checking phos levels after injectafer (stretch), or you have a person that had a serious infusion reaction to IV iron in the past and you’re switching formulations? But aside from that it's just not a high risk med.
Thinking it out that way, I’m not sure how often (if ever) I’d have 2 of 3 elements land in the “high” category, so I just click 4 and call it a day.
