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If a provider gives 800mg ibuprofen would this be a low or moderate MDM. I feel a low since you can get this otc. Provider wants to see this in written can you please help me. Thank you.
I don't think you can make an accurate determination of risk based on this single piece of information alone, and I don't think you'll find anything in writing to say it has to be one way or the other. The E&M Documentation Guidelines state that "Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk." So whether the drug is prescription or OTC is really of less relevance than the nature of the presenting problem. You really have to look at the big picture of what problems are being evaluated or treated and what kinds of risks are identified in the documentation to assess accurately what the patient's risk level is for the MDM of the encounter. A good tool I'd suggest looking at to help you resolve this with the provider is Appendix C in the CPT book which gives clinical examples from many different specialties of the different E&M codes for comparison.
*The lateral epicondylitis was a new problem without further workup. *The ibuprofen was new medication. *therefore, MDM was moderate and should have been a level 4

This was the provider response. Est. patient. He gave a 99214 I said 99213 because the problem was est and the 800mg was low.
I'd have to see the whole note to be able to say which code I would choose, but that's OK. Different providers and different coders will frequently come up with different levels and that's to be expected. 800 mg is a prescription dose of ibuprofen (400 mg is OTC) so the provider does have that in their favor. Either way, if it's just coming down to risk, the difference between 99213 and 99214 is rather small and not worth a big fight. As long as the services were medically necessary and properly documented, I'd let something like this go.

A couple of suggestions for dealing with providers on this issue that I've received from experienced auditors: 1) if the coder comes up with a different level than the provider, call this a 'variance' in coding rather than an 'error' on the provider's part - treat it like an FYI to let the provider know that an auditor did not agree with their coding and explain why. 2) Rather than looking just at right code vs. wrong code, consider how serious the error is. A difference in one level based on a single element in the documentation is relatively minor compared to things like unsigned or missing notes or sections of notes, incorrect use of copy/paste, substantial upcoding of levels. These are where your bigger audit risks are. 3) Allow the provider the opportunity to appeal your decisions (sounds like you're doing that here). The provider's reasoning for their choice is something that you can use to defend their levels if a payer audits. You may win some and lose some, but I've always felt that as long as you can justify in writing why a code was chosen, you're doing the right thing. Hope all this helps some!
Re: Prescription Drug Management

Postby Shannon DeConda » Thu Jul 17, 2014 7:02 pm

Thank you but found this:

Prescription drug management has to do with drugs that can only be attained through a physician order (prescription) and are managed by the physician. The physician assigns a liability and amount of responsibility to assess for patient risk when a patient receives these medications, therefore a higher level is warranted with moderate risk. Over-the-counter medications, even at a prescription dose, are still a lower level of risk based on the classification and management process of the medication. The fact that a prescription was written for an over-the-counter medicine is not enough to warrant it as prescription drug management. This also applies to medications where the insurance will pay if a prescription is written; the logistics of writing an Rx alone do not allow for the consideration of this drug as prescription management. Review the documentation content for an actual management process. If the provider gives the patient a prescription for Prilosec to "manage" their chronic upper gastric complaints, there is management involved and not merely script writing. Be sure to evaluate the records thoroughly and not just automatically give credit for all prescriptions written.

Per the NAMAS medical auditing tip by our team mate sara san pedro written on 6-13-2014

Thank you,
Founder & President of NAMAS