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Purpose of Review
To summarize the effects of long-term osteoporosis drug treatment and of osteoporosis drug treatment discontinuation and holidays.
Key Messages
- Evidence on the effects of long-term osteoporosis drug treatment and drug continuation versus discontinuation is mostly limited to white, healthy, postmenopausal women.
- Long-term alendronate reduces radiographic vertebral and nonvertebral fractures in women with osteoporosis; long-term zoledronate reduces vertebral and nonvertebral fractures in women with osteopenia or osteoporosis.
- Long-term bisphosphonates may increase atypical femoral fractures and osteonecrosis of the jaw, although both are rare.
- In women with osteoporosis, long-term raloxifene reduces vertebral fractures, but not hip or nonvertebral fractures, and increases venous thromboembolism.
- Long-term oral hormone therapies reduce hip and clinical fractures but increase multiple serious harms.
- Evidence is insufficient about the effects of long-term denosumab, risedronate, ibandronate, teriparatide, and abaloparatide on fractures and harms.
- Continuing bisphosphonates after 3–5 years versus discontinuation reduces some measures of vertebral fractures, but not nonvertebral fractures.
Structured Abstract
Objective. To summarize the effects of long-term osteoporosis drug treatment (ODT) and ODT discontinuation and holidays on fractures and harms.
Data sources. MEDLINE®, Embase®, and Cochrane databases from 1995 to October 2018; ClinicalTrials.gov; bibliographies of relevant systematic reviews.
Review methods. We defined long-term ODT as >3 years and ODT holidays as discontinuation for ≥1 year after ≥1 year of use. Trials were used for incident fractures and harms, and controlled observational studies were included for additional harms. Two investigators rated risk of bias. For studies with low or medium risk of bias, one investigator extracted data and a second verified accuracy. Two investigators graded strength of evidence (SOE).
Results. Sixty-one English-language studies were included. In women with osteoporosis, 4 years of alendronate reduced clinical fractures (hazard ratio [HR] 0.64 [95% confidence interval (CI) 0.50, 0.82]) (moderate SOE) and radiographic vertebral fractures (HR 0.50 [95% CI 0.31, 0.82]) (moderate SOE), while 4 years of raloxifene reduced clinical vertebral fractures (relative risk 0.58 [95% CI 0.43, 0.79]) (high SOE), but not hip (moderate SOE) or nonvertebral fractures (high SOE). In women with osteopenia or osteoporosis, 6 years of zoledronate reduced incident clinical fractures (HR 0.73 [95% CI 0.60, 0.90]) (moderate SOE) and clinical vertebral fractures (HR 0.41 [95% CI 0.22, 0.75]) (moderate SOE). In postmenopausal women with unknown osteoporosis or osteopenia status, both long-term oral estrogen and estrogen/progestin reduced clinical fractures (high SOE) and hip fractures (moderate SOE). After 3–5 years of prior treatment, continuation of zoledronate or alendronate versus drug holiday inconsistently reduced incident vertebral fracture outcomes (radiographic only for zoledronate [low SOE], clinical only for alendronate [moderate SOE]), but did not reduce nonvertebral fractures (low SOE). Hormone therapies increased cardiovascular events, mild cognitive impairment or dementia, and other harms. Observational studies showed that long-term bisphosphonates may increase atypical femoral fractures (AFF) (low SOE) and osteonecrosis of the jaw (low SOE in 2 comparisons, insufficient in 1).
Limitations. Most data were from white, healthy, postmenopausal women, limiting generalizability. Trials often had low power for incident clinical fractures. No trials compared active treatments, sequential treatments, or different durations of drug holidays. Harms and controls were inconsistently defined.
Conclusions. Long-term alendronate, zoledronate, and oral hormone therapy reduced nonvertebral fractures in older women, with oral hormone therapy also reducing hip fractures. While absolute reductions in typical fractures with long-term bisphosphonates are large relative to increases in AFF, reduced hip fracture risk with oral hormone therapy appears offset by increased risk of serious harms. Evidence is limited regarding ODT holidays for fractures and harms. Future research is needed, including randomized trials comparing ODT holiday durations and sequential treatments powered for clinical fractures, and controlled cohort studies of ODT holidays to estimate rare harms.
Citation
Suggested citation: Fink HA, MacDonald R, Forte ML, Rosebush CE, Ensrud KE, Schousboe JT, Nelson VA, Ullman K, Butler M, Olson CM, Taylor BC, Brasure M, Wilt TJ. Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review. Comparative Effectiveness Review No. 218. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2015-00008-I) AHRQ Publication No. 19-EHC016-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER218.
Code: Z79.899
Code Name: ICD-10 Code for Other long term (current) drug therapy
Block: Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99)
Code also any follow-up examination (Z08-Z09)
Details: Other long term (current) drug therapy
Z79
Code also: any therapeutic drug level monitoring (Z51.81)
Includes: long term (current) drug use for prophylactic purposes
Excludes2: drug abuse and dependence (F11-F19)
drug use complicating pregnancy, childbirth, and the puerperium (O99.32-)
long term (current) use of oral antidiabetic drugs (Z79.84)
long term (current) use of oral hypoglycemic drugs (Z79.84)”
Guidelines: Factors influencing health status and contact with health services (Z00-Z99)
Note: Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y99 are recorded as ‘diagnoses’ or ‘problems’. This can arise in two main ways:
(a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
(b) When some circumstance or problem is present which influences the person’s health STATUS but IS NOT IN itself a CURRENT illness OR injury.
FOR more details ON Z79.899, ICD-10 CODE FOR Other LONG term (CURRENT) drug therapy, visit:
: Z79.899: ICD-10 Code for Other long term (current) drug therapy: Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99)Code also any follow-up examination (Z08-Z09): Other long term (current) drug therapyZ79: any therapeutic drug level monitoring (Z51.81): long term (current) drug use for prophylactic purposes: drug abuse and dependence (F11-F19)drug use complicating pregnancy, childbirth, and the puerperium (O99.32-)long term (current) use of oral antidiabetic drugs (Z79.84)long term (current) use of oral hypoglycemic drugs (Z79.84)”: Factors influencing health status and contact with health services (Z00-Z99): Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y99 are recorded as ‘diagnoses’ or ‘problems’. This can arise in two main ways:(a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.(b) When some circumstance or problem is present which influences the person’s health STATUS but IS NOT IN itself a CURRENT illness OR injury.FOR more details ON Z79.899, ICD-10 CODE FOR Other LONG term (CURRENT) drug therapy, visit: https://www.aapc.com/codes/icd-10-codes/Z79.899
Patients taking Plaquenil (hydroxychloroquine, Sanofi-Aventis) on a long-term basis may leave you scratching your head when it comes to coding the patient encounters. Although coding for long-term medications is not a difficult process, it often involves communicating with other physicians or specialists to obtain accurate information. While this clinical example focuses on Plaquenil, the concept works for any long-term medication.
ICD-10 Classifications
The ICD-10 section that covers long-term drug therapy is Z79, with many subsections and specific diagnosis codes.
Because Plaquenil does not have its own specific category, clinicians should use Z79.899—Other Long Term (Current) Drug Therapy. But getting the right code is just one step in the process of correctly documenting the encounter.
ICD-10 Codes for Long-term Therapies
Code
Long-term (current) use of
V – Valid For Claim Submission
Z79.01
anticoagulants
Z79.02
antithrombotics/antiplatelets
Z79.1
NSAIDs
Z79.2
antibiotics
Z79.3
hormonal contraceptives Z79.4
insulin
Z79.51
inhaled steroids
Z79.52
systemic steroids
Z79.810 selective estrogen receptor modulators
Z79.811
aromatase inhibitors
Z79.818
other agents affecting estrogen receptors and estrogen levels
Z79.82
aspirin
Z79.83
bisphosphonates
Z79.84
oral hypoglycemic drugs
Z79.891
opiate analgesic
Z79.899
other drug therapy
H – Not Valid for Claim Submission
Z79
drug therapy
Z79.0
anticoagulants and antithrombotics/antiplatelets
Z79.5
steroids
Z79.8
other drug therapy
Z79.81
agents affecting estrogen receptors and estrogen levels
Z79.89
other drug therapy
Code the Condition
When coding for these individuals, it is important to understand the mechanism in place. The patient is taking a long-term medication for a specific systemic condition, such as rheumatoid arthritis (RA), so the first step is coding for that. This is where communication with other physicians is paramount. You and the patient’s other providers need to remain consistent with the ICD-10 code used to describe the condition for which the patient is being treated. Once you know the primary systemic condition, you can code the medication use and any adverse effects that require further attention.
Example: Plaquenil
Here’s the coding for a patient taking Plaquenil for RA:
1. Report M06.08 for RA, other, or M06.9 for RA, unspecified (always report the systemic disease state first).
2. Report Z79.899 for Plaquenil use for RA.
3. Always report both. Link to both, and if the carrier does not pay on the Z code, link to the M code first (or only link to the M code).
4. If maculopathy is present, report the adverse effect of the hydroxychloroquine as well:
T37.2x5A: Adverse effect of anti-malarials and drugs acting on other blood protozoa, initial encounter.
T37.2x5D: Adverse effect of anti-malarials and drugs acting on other blood protozoa, subsequent encounter.
T37.2x5S: Adverse effect of anti-malarials and drugs acting on other blood protozoa, sequela.
Understanding what you are clinically evaluating in a patient taking long-term medications and following the basic ICD-10 rules will help you be quite successful in caring for these patients and adding a valuable care component to your practice.
Send questions and comments to [email protected].
