Good discussion. If the provider is being paid for the drug (J code) and the administration (e.g. 20610/20611), how can we also count that separately towards the E/M MDM? My opinion is I wouldn't call it prescription drug management. I go back to the work RVUs and credit already being given. They injected it at the time of service and monitored the patient pre and post procedure if we are only talking cortisone/joint injections. Again, it's a good discussion and I can see both sides of it. The separate E/M would also have to be billable in the first place and support a 25 mod.
Some reading material:
Best explanation here:
Drugs that are injected in the office are certainly of RX strength; however, the coding of the service rendered may prevent it from counting as RX management. CPT codes when the injectable is a procedural service and performed by an MD/NP/PA provider
have the risk of the drug already allocated as part of the wRVUs of the provider. Injections administered IM/SubQ by ancillary staff can also be billed independent of an E&M, but they are represented by CPT codes with provider wRVUs that only reflect a supervision level of service of staff. Therefore, the risk of management of the drug (3rd column of MDM) has not been pre-allocated.
This one is a little odd:
Is an in-office injection considered prescription drug management?
Injections administered in the office are not prescribed via pharmacy; they are billed as DME using HCPCS J code. The patient is then observed for adverse effects by physician or ancillary staff as considered in the CPT® administration code; therefore, it is not considered part of the risk in medical decision making of an E/M code under prescription drug management.
CMS states:
The term “administered” refers only to the physical process by which the drug enters the patient’s body. It does not refer to whether the process is supervised by a medical professional (for example, to observe proper technique or side-effects of the drug). Injectable drugs, including intravenously administered drugs, are typically eligible for inclusion under the “incident to” benefit. With limited exceptions, other routes of administration including, but not limited to, oral drugs, suppositories, topical medications are considered to be usually self-administered by the patient.
- Can we always give a moderate level of risk using the example of “prescription drug management” when we order an injection for the patient?
Answer: Ordering an injection for the patient is not prescription drug management. There can be many different reasons for ordering injections including, but not limited to, birth control, cancer treatments, joint issues, allergies and antibiotics. The column of risk is “Risk of Complications and/or Morbidity or Mortality of Patient Management.” The MDM table includes examples of situations that could fall under that category of risk. The AMA definition of morbidity reads “A state of illness or functional impairment that is expected to be a substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.” The AMA definition of risk reads in part: “The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of event under consideration.” “Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified healthcare professional in the same specialty.” “For the purposes of MDM, level of risk is based on consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.” Choose the level of risk based on the physician or other qualified health care professional’s determination and documentation of the risk to that specific patient for that specific encounter for that specific treatment choice. Billing for the administration of the injection and drug show the decision for that treatment.
This one has interesting thoughts:
Drugs that are injected in the office are certainly of RX strength; however, the coding of the service rendered may prevent it from counting as RX management. CPT codes when the injectable is a procedural service and performed by an MD/NP/PA provider
have the risk of the drug already allocated as part of the wRVUs of the provider. Injections administered IM/SubQ by ancillary staff can also be billed independent of an E&M, but they are represented by CPT codes with provider wRVUs that only reflect a supervision level of service of staff. Therefore, the risk of management of the drug (3rd column of MDM) has not been pre-allocated.