Questions and Answers for Coding Opiods in Section N0410H

Members | November 15, 2017 | by Judy Wilhide

Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Question: Is Tramadol coded in N0410H as an opioid?

Answer: Yes.

Rationale: The RAI manual, N-11, lists four websites as reliable guidance for determining a drug’s classification:

The following resources and tools provide information on medications including classifications, warnings, appropriate dosing, drug interactions, and medication safety information.

  • GlobalRPh Drug Reference, http://globalrph.com/drug-A.htm
  • USP Pharmacological Classification of Drugs, http://www.usp.org/usp-healthcare-professionals/usp-medicare-model-guidelines/medicare-model-guidelines-v50-v40#Guidelines6. Directions: Scroll to the bottom of this webpage and click on the pdf download for “USP Medicare Model Guidelines (With Example Part D Drugs)”
  • Medline Plus, https://www.nlm.nih.gov/medlineplus/druginformation.html
  • The DrugLib.com Index of Drugs by Category, http://www.druglib.com/drugindex/category/

This list is not all-inclusive. CMS is not responsible for the content or accessibility of the pages found at these sites. URL addresses were current as of the date of this publication.

Two of these references lists Tramadol as a synthetic opioid and two list it as an opioid analgesic:

  • Synthetic Opioid
    • GlbalRPh Drug Reference
    • Druglib.cm
  • Opioid Analgesic
    • USP Pharmaclogical Classification of Drugs
    • Medlineplus.gv

Page N-7 has the following coding tips:

  • Code medications in Item N0410 according to the medication’s therapeutic category and/or pharmacological classification, not how it is used. For example, although oxazepam may be prescribed for use as a hypnotic, it is categorized as an antianxiety medication. Therefore, in this section, it would be coded as an antianxiety medication and not as a hypnotic.
  • Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. For example, prochlorperazine is dually classified as an antipsychotic and an antiemetic. Therefore, in this section, it would be coded as an antipsychotic, regardless of how it is used.

Therefore, since the recommended references classify Tramadol as both a synthetic opioid and an opioid analgesic, it is to be coded as an opioid in N0410H.

My resident is receiving a Fentanyl patch for pain control. Do I code 7 days of an opioid or 2 days since the patch is changed every 3 days and it was changed twice during my lookback period?

Answer: Code the number of times the patch is placed.

Rationale:

Page N-7 of the RAI Manual has this coding tip:

Count long-acting medications, such as fluphenazine decanoate or haloperidol decanoate, that are given every few weeks or monthly only if they are given during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

According to GlobalRPH Drug Reference, both of these antipsychotics are injections that are usually given once monthly, or in the case of Fluphenazine decanoate, given every 4-6 weeks. They are long-acting and can take 1-3 days to notice the effect.

Fentanyl patch is not an injection. When Fentanyl is given I.M, doses have a duration of 1-2 hours. Single I.V. doses last 0.5-1 hour. When Fentanyl is given in a transdermal patch, it delivers a continuous dose ranging from 25 to 100mcg/hr. After initial application, a depot of fentanyl forms in the upper skin layers and serum fentanyl concentrations increase gradually, generally levelling off between 12 and 24 h. steady-state serum concentration is reached after 24 h and maintained as long as the patch is renewed. (Information about Fentanyl obtained from GlobalRPH Drug Refernce. Information about the transdermal patch use and function obtained from the manufacturer’s website.)

So, Fentanyl in a transdermal patch is in a controlled, time-released delivery system, making it “long-acting” when delivered via transdermal patch. This is why you count the number of days the patch is applied in the seven day lookback period.