Wiki Prescription Drug Management

jkottarathil

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Hello all,

I have a question in regards to prescription drug management for MDM purposes that myself and other coders in our department have been questioning back and forth for a few months. We work exclusively in the domiciliary and home setting
(95/97 guidelines). The patients our providers provide "in-home" care for are in assisted living facilities and independent living facilities.

We constantly see it where the providers are writing prescriptions for OTC medications (for multiple reasons--a higher dosage of ibuprofen/Tylenol that you cannot get OTC, another example would be prescribing melatonin and getting it from the pharmacy rather than OTC). Our patient population typically does not leave their home setting. Their medications are managed by the primary care provider and ALF nursing staff (nursing coordinates with pharmacy). Here's an example, the patient is confined to their home. Our medical provider wrote this order: Refill: Tab-a-Vite 1 tab per G tube once daily. 30 days, Refills: 11, Qty: 30. Nursing staff sent the order to the patient's pharmacy.

Our question is even though they are OTC drugs, since we are prescribing them and it is coming from the pharmacy are we able to count this as prescription drug management for MDM purposes? Or would we have to drop it down to low risk for OTC drug management?
 
In my opinion this would constitute prescription drug management. They are managing it, making decisions and the pharmacy is involved. Even if the drug is available OTC, they are prescribing it and it's part of the MDM. They are also considering it along with all the other medications and conditions the patient may have.

I found this on FCSO:

E/M FAQ -- What constitutes prescription drug management?

Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication or dosage.
Note: Simply listing current medications is not considered "prescription drug management."
"Prescription drug management" does differ from "drug therapy requiring intensive monitoring for toxicity".

NGS says:
  1. Please define prescription drug management relative to MDM.
Answer: In order to count prescription drug management there must be:

  1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
  2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
  3. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
  4. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.
Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

Novitas: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056
4. When can prescription drug management be credited in the medical decision-making risk of complications chart?
Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.
If medications are just listed in patient’s medical record, credit is given for past history.
 
Hi JKott💊:)
I agree with Amyjh. The providers are managing it but also include the Z dx codes of Z76 or Z51.81 as last dx code according to managing or prescribing medications documented in their daily notations.
Lady T
 
In my opinion this would constitute prescription drug management. They are managing it, making decisions and the pharmacy is involved. Even if the drug is available OTC, they are prescribing it and it's part of the MDM. They are also considering it along with all the other medications and conditions the patient may have.

I found this on FCSO:

E/M FAQ -- What constitutes prescription drug management?

Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication or dosage.
Note: Simply listing current medications is not considered "prescription drug management."
"Prescription drug management" does differ from "drug therapy requiring intensive monitoring for toxicity".

NGS says:
  1. Please define prescription drug management relative to MDM.
Answer: In order to count prescription drug management there must be:

  1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
  2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
  3. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
  4. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.
Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

Novitas: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056
4. When can prescription drug management be credited in the medical decision-making risk of complications chart?
Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.
If medications are just listed in patient’s medical record, credit is given for past history.
I've been meaning to respond to this for weeks, but I keep forgetting. Thank you so much for this information! This was very very helpful! A+ answer!
 
Hello all,

I have a question in regards to prescription drug management for MDM purposes that myself and other coders in our department have been questioning back and forth for a few months. We work exclusively in the domiciliary and home setting
(95/97 guidelines). The patients our providers provide "in-home" care for are in assisted living facilities and independent living facilities.

We constantly see it where the providers are writing prescriptions for OTC medications (for multiple reasons--a higher dosage of ibuprofen/Tylenol that you cannot get OTC, another example would be prescribing melatonin and getting it from the pharmacy rather than OTC). Our patient population typically does not leave their home setting. Their medications are managed by the primary care provider and ALF nursing staff (nursing coordinates with pharmacy). Here's an example, the patient is confined to their home. Our medical provider wrote this order: Refill: Tab-a-Vite 1 tab per G tube once daily. 30 days, Refills: 11, Qty: 30. Nursing staff sent the order to the patient's pharmacy.

Our question is even though they are OTC drugs, since we are prescribing them and it is coming from the pharmacy are we able to count this as prescription drug management for MDM purposes? Or would we have to drop it down to low risk for OTC drug management?
I would recommend you research further. OTC medications, regardless if they were prescribed, would be low risk, unless there are other conditions that would increase the risk to the patient. I see it often where omeprazole is prescribed to the patient, but it is also an OTC drug. Dosage is 20mg. This would not warrant moderate complexity, even though it was "prescribed." Some Rx's are ordered for insurance to cover, even if they are obtainable OTC. I recently read a response from a physican in this forum that addressed this very same question.
 
It seems until the E/M guidelines provide further guidance on what falls under Prescription Drug Managaement, this will continue to be a frequent topic of discussion. Historically, in the '95/'97 table of risk guidelines, Over-the-counter drugs were placed into 'low' risk while prescription drug management was considered 'moderate risk'. Using the information provided by amyjpgh, if we consider OTC medicine to be prescription drug management, then in what circumstance would you apply over-the-counter drugs in the low-risk section of MDM?

According to the FDA:
Over-the-counter medicine is also known as OTC or nonprescription medicine. All these terms refer to medicine that you can buy without a prescription. They are safe and effective when you follow the directions on the label and as directed by your health care professional.

Just wanted to put my two cents in as this is something I am also trying to look into to find a concrete answer, but it does not look like the E/M guidelines will further clarify in this regard for the time being.
 
It's definitely a grey area.
If the record does not clearly indicate anything that would make it more or less complex in this specific patient's case, then I consider OTC low risk and Rx moderate risk. By Rx, I mean a medication that requires a prescription (not just for administrative reasons) and is not available over the counter.
I like this AAFP reference:
If you are billing based on MDM, you can include decisions about prescription medications, but over-the-counter (OTC) medications generally don't meet moderate complexity. If you use OTC medications in that context, just state why the decision was higher risk. A prescription for an OTC medication for insurance coverage purposes does not meet this threshold.
Summary - it is possible for an OTC med to be moderate risk, but that complexity must be sufficiently documented.
 
I would recommend you research further. OTC medications, regardless if they were prescribed, would be low risk, unless there are other conditions that would increase the risk to the patient. I see it often where omeprazole is prescribed to the patient, but it is also an OTC drug. Dosage is 20mg. This would not warrant moderate complexity, even though it was "prescribed." Some Rx's are ordered for insurance to cover, even if they are obtainable OTC. I recently read a response from a physican in this forum that addressed this very same question.
I agree completely. An OTC drug does not automatically become 'prescription drug management' just because the provider prescribed it. It is definitely low risk, that is why it is available over the counter.
 
It's definitely a grey area.
If the record does not clearly indicate anything that would make it more or less complex in this specific patient's case, then I consider OTC low risk and Rx moderate risk. By Rx, I mean a medication that requires a prescription (not just for administrative reasons) and is not available over the counter.
I like this AAFP reference:
If you are billing based on MDM, you can include decisions about prescription medications, but over-the-counter (OTC) medications generally don't meet moderate complexity. If you use OTC medications in that context, just state why the decision was higher risk. A prescription for an OTC medication for insurance coverage purposes does not meet this threshold.
Summary - it is possible for an OTC med to be moderate risk, but that complexity must be sufficiently documented.
If there is a moderate risk associated with the decision to use a drug, it would not be available over the counter. If the provider is deciding to have the patient use a drug that is available OTC, then it is low risk, regardless of whether they order a prescription or just ask the patient to go buy the medication OTC. Complexity of diagnoses or comorbidities or other management options selected do not affect the risk associated with the decision to use an OTC medication.
 
In my opinion this would constitute prescription drug management. They are managing it, making decisions and the pharmacy is involved. Even if the drug is available OTC, they are prescribing it and it's part of the MDM. They are also considering it along with all the other medications and conditions the patient may have.

I found this on FCSO:

E/M FAQ -- What constitutes prescription drug management?

Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication or dosage.
Note: Simply listing current medications is not considered "prescription drug management."
"Prescription drug management" does differ from "drug therapy requiring intensive monitoring for toxicity".

NGS says:
  1. Please define prescription drug management relative to MDM.
Answer: In order to count prescription drug management there must be:

  1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
  2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
  3. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
  4. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.
Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

Novitas: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056
4. When can prescription drug management be credited in the medical decision-making risk of complications chart?
Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.
If medications are just listed in patient’s medical record, credit is given for past history.
Disagree. An OTC medication is low risk, that is why it is available over the counter. An OTC drug, by definition, means a NON-PRESCRIPTION drug. It does not become 'prescription drug management' just because the provider decided to write a prescription for it. A drug that is available OTC would be a prescription drug only if the strength available OTC is lower than the strength prescribed by the provider. Again, the definition stands - the higher strength ordered by the provider is not available OTC, that is why it is a prescription. The moderate risk column in the MDM table refers to 'prescription' drug management, not just any management.
 
If there is a moderate risk associated with the decision to use a drug, it would not be available over the counter. If the provider is deciding to have the patient use a drug that is available OTC, then it is low risk, regardless of whether they order a prescription or just ask the patient to go buy the medication OTC. Complexity of diagnoses or comorbidities or other management options selected do not affect the risk associated with the decision to use an OTC medication.
Per the AAFP article, it is possible for an OTC drug to meet moderate risk, which is why I specifically included the link to my reference. Perhaps a patient is in renal failure and a provider needs to alter/titrate an OTC med specific to that patient and their lab work. Yes, it's unusual but certainly POSSIBLE and must be documented, which was my statement. The AMA guidelines chart under risk specifically state "EXAMPLES ONLY". That does not mean it's not possible for something to fall into another category or something not listed to be that level. There are not even any examples given for low risk on 2021 guidelines.
The full AMA 2021 guidelines reference risk several times that the patient's problems can affect the risk:
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon 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.
The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.

Therefore, OTC is not 100% of the time low risk. Maybe 99% of the time, but not 100%. If my physician documents in the note why an OTC med is moderate risk, then it is moderate risk.
In this post, I am again providing and linking my references.
 
NAMAS (National Alliance of Medical Auditing Specialists) just put out a "cheat sheet" about this. I do not know what their sources were, but I agree with the concept (at the very least):
"There are basically 2 major requirements in order to support Rx management:
1. Prescriptive authority is required. If it doesn't require prescriptive authority by the FDA, then Rx management is not met.
2. Initiation, modification, discontinuation, or continuation of a Rx medication is management. "Management' is not based on the length of the course of drug treatment, but rather the management of the patient during the course of the treatment"

it continues:
"OTC medications do not require prescriptive authority, and based on MDM complexity have a 'low' risk for management. OTC medications often come as a Rx, but this does NOT raise their risk level for MDM complexity."
"Some medications come as both OTC & Rx, but the formulary and directions are the same. In this scenario, the risk of management would be OTC (the lower) as the FDA, by removal of prescriptive authority is noting this as OTC risk"

this is the most straight-forward explanation I have heard.
Again, I don't know what their sources were, but I have respect for the organization and this makes sense to me.
 
I do agree that OTC is almost always low risk. Maybe even 99.9% of the time. I am simply saying it is possible to be moderate risk in an unusual circumstance and properly documented. The fact that the provider wrote an OTC on an Rx pad with specific directions does not meet that situation. I am not saying and OTC medication equals prescription management. I am saying the table provides examples, and it is possible for something not given as an example to meet the level of risk.
The AMA guideline defines risk "Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated."
I would credit moderate risk for a provider who stated in the record that an OTC med was moderate risk with an explanation of why. The provider is the trained clinician and I do not have the education, skill, or background to question a provider's clinical judgment.
 
I do agree that OTC is almost always low risk. Maybe even 99.9% of the time. I am simply saying it is possible to be moderate risk in an unusual circumstance and properly documented. The fact that the provider wrote an OTC on an Rx pad with specific directions does not meet that situation. I am not saying and OTC medication equals prescription management. I am saying the table provides examples, and it is possible for something not given as an example to meet the level of risk.
The AMA guideline defines risk "Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated."
I would credit moderate risk for a provider who stated in the record that an OTC med was moderate risk with an explanation of why. The provider is the trained clinician and I do not have the education, skill, or background to question a provider's clinical judgment.

I agree with you, Christine.
My post was not to disagree with your point, but to point out some more specific guidelines.

every case has to be looked at individually.
 
Hello all,

I have a question in regards to prescription drug management for MDM purposes that myself and other coders in our department have been questioning back and forth for a few months. We work exclusively in the domiciliary and home setting
(95/97 guidelines). The patients our providers provide "in-home" care for are in assisted living facilities and independent living facilities.

We constantly see it where the providers are writing prescriptions for OTC medications (for multiple reasons--a higher dosage of ibuprofen/Tylenol that you cannot get OTC, another example would be prescribing melatonin and getting it from the pharmacy rather than OTC). Our patient population typically does not leave their home setting. Their medications are managed by the primary care provider and ALF nursing staff (nursing coordinates with pharmacy). Here's an example, the patient is confined to their home. Our medical provider wrote this order: Refill: Tab-a-Vite 1 tab per G tube once daily. 30 days, Refills: 11, Qty: 30. Nursing staff sent the order to the patient's pharmacy.

Our question is even though they are OTC drugs, since we are prescribing them and it is coming from the pharmacy are we able to count this as prescription drug management for MDM purposes? Or would we have to drop it down to low risk for OTC drug management?
Hello all,

I have a question in regards to prescription drug management for MDM purposes that myself and other coders in our department have been questioning back and forth for a few months. We work exclusively in the domiciliary and home setting
(95/97 guidelines). The patients our providers provide "in-home" care for are in assisted living facilities and independent living facilities.

We constantly see it where the providers are writing prescriptions for OTC medications (for multiple reasons--a higher dosage of ibuprofen/Tylenol that you cannot get OTC, another example would be prescribing melatonin and getting it from the pharmacy rather than OTC). Our patient population typically does not leave their home setting. Their medications are managed by the primary care provider and ALF nursing staff (nursing coordinates with pharmacy). Here's an example, the patient is confined to their home. Our medical provider wrote this order: Refill: Tab-a-Vite 1 tab per G tube once daily. 30 days, Refills: 11, Qty: 30. Nursing staff sent the order to the patient's pharmacy.

Our question is even though they are OTC drugs, since we are prescribing them and it is coming from the pharmacy are we able to count this as prescription drug management for MDM purposes? Or would we have to drop it down to low risk for OTC drug management?
NAMAS has an article on this that says OTC meds to not count because they do not require prescriptive authority (meaning the FDA requires a valid Rx), and based on MDM have a low risk for management. Even if they can come as a Rx, if it doesn't need prescriptive authority, it does not raise the complexity of MDM. Link for article: https://namas.co/wp-content/uploads/2022/10/Modifier-25-RX-Management.pdf
 
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