Question Oral Medications in Emergency Room

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I am having difficulty finding an answer to this question. A patient is given an Oral tablet of Zithromax during the ER visit. While leveling the E/M for this ER visit, can this medication be considered an over-the-counter medication under the Table of Risk since it was given orally? The patient wasn't given a prescription for any medication during this visit so I don't feel Prescription Drug Management fits. Any help is appreciated!
 
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Ok, yes I'm looking for the Pro-Fee side. When coding the ER visit (99281-99285), under MDM, if the patient is given Oral Meds During the visit, can I consider this as "over the counter medications" under Management Options for the Table of Risk? I appreciate your answer.
 

sarah3065

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I am having difficulty finding an answer to this question. A patient is given an Oral tablet of Zithromax during the ER visit. While leveling the E/M for this ER visit, can this medication be considered an over-the-counter medication under the Table of Risk since it was given orally? The patient wasn't given a prescription for any medication during this visit so I don't feel Prescription Drug Management fits. Any help is appreciated!
I code it as low risk when, on discharge, the MD is recommending treatment of the patient's condition with an OTC...such as "use icy hot, alternate ibuprofen and tylenol"
 

thomas7331

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Zithromax is not an over-the-counter drug - it doesn't make a difference that it was given orally.

Whether or not you should count it as 'prescription drug management' on the table of risk is another question. You have to keep in mind that, as the guidelines state, the table of risk "includes common clinical examples rather than absolute measures of risk". To estimate the risk at the given encounter, it's necessary to consider the prescription drug in the context of all of the provider's documentation. In experience, most auditors would not assign a moderate level of risk just based solely on the provider's giving a single dose of a prescription medication unless there are other factors involved that would warrant it.
 
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