Wiki Telephone visit vs E/M

[raeven.rojas@gmail.com]

If the provider spoke with a home health nurse regarding a patient on 06/03 and called in a prescription due to signs of infection. THEN sees the patient on 6/10 and states that the patient completed the antibiotic today (6/10) does the provider bill the 6/10 E/M visit and include the Rx in their level of MDM?
They did NOT bill a telehealth encounter as they only spoke with the nurse.

 

[sathiya]

Maybe — but only if the provider actively evaluated the effectiveness or outcome of that medication.
Just noting that the patient completed the antibiotic is not enough to count as “prescription drug management.”
There must be active clinical assessment of the treatment and condition.

You can count it if the note includes something like:
“Patient completed 7-day course of antibiotics prescribed on 6/3. Reports decreased redness and no further signs of infection. No additional treatment required at this time.”
This shows the provider is assessing the response to the medication and making a management decision (continue monitoring, no further Rx, etc.).
That meets the criteria for moderate MDM (prescription drug management).

You cannot count it if the note only says:
“Patient completed antibiotics.”
This is just a status update, not a management decision. In this case, you wouldn’t count Rx management in the MDM level.

 

[raeven.rojas@gmail.com]

Thank you for your response! This is very helpful.

As a follow up, how/can the provider bill for the telephone conversation with the home health nurse when the antibiotic was originally ordered? I'm a newer coder and only see telephone visits with patient's (and I've seen alot of information that these codes are no longer to be used)

 

[jkyles]

Hi there, was the conversation with the nurse related to a service for the patient? For example, the provider saw the patient and also spoke to the nurse? I agree that typically a standalone call with the nurse would not be reported. So far as coverage of telephone calls with patients are concerned, it depends on the service and the payer.

 

[raeven.rojas@gmail.com]

Hi there, was the conversation with the nurse related to a service for the patient? For example, the provider saw the patient and also spoke to the nurse? I agree that typically a standalone call with the nurse would not be reported. So far as coverage of telephone calls with patients are concerned, it depends on the service and the payer.

Yes, the patient had been seen a week prior for wound care management and was "resolved " at the time of the visit. The home health nurse called a week after this visit stating the wound reopened and had purulent drainage which is why the provider ordered the antibiotic. Pt was then scheduled for a follow up which is when the abx had already been completed.