Rx management when patient already has pills at home?

[wynonna]

Hello
Our provider told a patient to resume her ciprodex drops.
The patient had been prescribed ciprodex at her Primary care so she had them at home. She had filled them from script given to her by her primary care MD.
Then she came to us, ENT providers and our provider advised patient to resume ciprodex.
Would that count as prescription management?
Would resuming ciprodex for otalgia count as prescription management?
thank you

 

[csperoni]

Prescription drug management is a decision to write, continue, discontinue, change dose. I would count an evaluation and order to resume a prescription medication as prescription drug management.

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

 

[dtricia]

I agree with that definition of drug management, but wonder about statements like ,'continue current regimen' without name the drug.

 

[csperoni]

Most EMRs will list the medications. If provider simply writes "continue current regimen" and no where in that documentation does it state that the regimen is a prescription medication, I would not credit it.
If a note stated under HPI for example, "DM II controlled with diet and metformin 500mg bid". At the end stated "continue current regimen for DM II", then I would count it.
You simply can't give credit if it's not documented.