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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