Improve medication adherence documentation and coding accuracy for Medication Noncompliance. This guide covers clinical indicators, diagnostic criteria, ICD-10 codes (Z91.128, Z91.19), SNOMED CT concepts, and best practices for healthcare professionals dealing with patient non-adherence to prescribed medications. Learn how to effectively document reasons for noncompliance, including patient refusal, financial barriers, and medication side effects, for improved patient care and accurate medical billing.
Also known as
Patient noncompliance with medication
Patient's nonadherence to prescribed medication regimen.
Problems related to medication
Difficulties related to medications, including compliance issues.
Problems related to lifestyle
Lifestyle factors affecting health, potentially influencing medication adherence.
Nonorganic sleep disorders
Sleep disturbances not due to organic causes, sometimes affecting medication schedules.
When to use each related code
| Description |
|---|
| Medication Noncompliance |
| Adverse Drug Reaction |
| Therapeutic Drug Monitoring |
Miscoding noncompliance (e.g., Z91.128, Z91.138) due to lack of clear documentation or coder misunderstanding.
Lack of specific evidence in the medical record to support the diagnosis of medication non-adherence, impacting CDI queries.
Coding noncompliance when patient refusal is due to financial hardship or other valid reasons, raising compliance concerns.
Patient presents with medication noncompliance, also referred to as medication nonadherence, regarding prescribed regimen for [Specific Condition, e.g., hypertension, diabetes mellitus type 2, hyperlipidemia]. The patient reports [Reason for noncompliance, e.g., forgetting to take medications, difficulty affording medications, concerns about side effects, intentional non-adherence due to beliefs about medication efficacy]. This nonadherence is evidenced by [Objective evidence, e.g., suboptimal therapeutic drug levels, uncontrolled blood pressure readings, elevated HbA1c, patient's self-report, pill counts]. The patient's current medication list includes [List current medications]. Risks associated with medication noncompliance were discussed with the patient, including potential for disease progression, exacerbation of symptoms, and increased risk of complications such as [Specific complications relevant to the underlying condition]. The patient's understanding of these risks was assessed. Strategies to improve medication adherence were explored and implemented, including [Specific strategies, e.g., medication reminders, pill organizers, patient education regarding medication importance and management of side effects, referral to social worker for financial assistance programs, dose simplification, shared decision-making regarding treatment plan]. Follow-up scheduled in [Timeframe] to monitor medication adherence and therapeutic response. Diagnosis codes considered include Z91.19 (Patient's noncompliance with other medical treatment and advice), and other relevant codes depending on the specific condition being treated. Patient education materials on medication adherence and disease management were provided.