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E&M level for over the counter drug

  1. Default E&M level for over the counter drug
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    For ER physician, if the history and exam are expanded problem and the physician gives an over the counter drug is that a level two 99282?

    What if the physician does not mark what type of drug was given but a prescription was given with and expanded problem history and exam? is that a level three 99283?

    Can someone explain how to calculate the risk and different diagnosis section of how to calculate the risk?


  2. #2
    Daytona Beach, FL
    For an ER visit, you must meet or exceed all three levels. If you have an Expanded Problem Focused History and Exam, it doesn't matter what your if the doctor gave an over the counter drug or RX - it would still only be 99282. To get a level 3 he would have to do at least a Detailed Exam and History along with the over the counter drug - which falls under a low risk. You also need to take into consideration the number of diagonsis/treatment options and data reviewed under the MDM portion - which could make this section higher or lower.

    If you go to and find the free Basic Coding webinar, it explains how to find your levels in easy to follow steps. This will go through how to determine your MDM level and explains the Risk table. You can also access an E/M audit tool from Highmark Medicare, Click on the Physician tab on top and then on the left there is a tab for Evaluation and Management - you will find the forms under there - this will take you step by step through finding your level.

    Hope this helps.
    Jodi Dibble, CPC

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