Page 1 of 2 12 LastLast
Results 1 to 10 of 15

Rx Drug Management - Does changing dosage

  1. #1
    Default Rx Drug Management - Does changing dosage
    Exam Training Packages
    Does changing dosage of a patient's meds count as Prescription Drug management? For example, does tapering off on a specific medication for a chronic headache count as Prescription management? Seems to me, yes. Any thoughts?

  2. #2
    Default
    Yes, it is - it requires the physician to make a medical decision, which carries a significant enough risk of complications to make the overall risk level moderate. Even tapering off of a medication could potentially produce harmful affects.


  3. #3
    Smile Rx Drug Management
    Thank you. Can you look at this Encounter, it is baffling me. Here it is:

    Pain location: Headache
    Pain Scale: 1
    Follow up on Headache and HTN.

    Allergies: Adhesive, Metformin, Ace Inhibitors

    He tried increasing metoproiol to 150mg bid with increase in HA noted. He called me by phone and I advised tapering metroproil down to current dosage of 50mg bid, which he has noted has helpd his HA to about 30 percent of prior severity. He said at it worst the HA feels like "a whack on the head." He does note that metropriol was also helpful in PVC Tx.

    His glycemic index is poor. Fasting glucose is is around 140, pm glucose is 120-140.

    Meds: Cozaar, Actos, Metroproli

    Phys Exam:
    GEn: Obese man in no distress
    HEENT: Temporal arteries nontender; Oropharnyx is benign.
    Lungs: Clear to asculation and percussion.

    IMpression: 1) Headache -- He is improved with with reduction of metroilol. Will continue to taper metroprioil by 50% every 10 days. Reacessment in a month.

    2) HTN -- See recommendations to taper off metroprioil. Reexam in a month.

    Initially, I got 99214. Det, exp, Moderate. What do you think?

  4. #4
    Default
    I agree with the overall assignment of 99214, but based mostly on the incidental hyperlipidemia and Rx management - the MDM is moderate. (Really? Beta blocker for a headache? I would have never considered that...). The history was also sufficient to be considered detailed, but I wouldn't have called the exam EPF. PF is really all that was documented. Since the patient is established, and the MDM was moderate, the lack of exam elements didn't really make much of an impact this time. If the provider had similar documentation with a new patient, though, they would have just docked themselves to a 99202 from a potential 99204. (Look up the price discrepency - I'm no doctor, but I'd sure take more notes if it would save me an extra $40 - $70 in contractual adjustments)

  5. #5
    Default Rx Drug Management
    THank you for your input, and I agree with your choice. What do you think about the medical necessity factor?

  6. #6
    Thumbs up
    It's definitely there - you have 3+ chronic conditions, 1 new undiagnosed problem with uncertain prognosis (hyperlipidemia), with specific co-morbidities to his current cardiovascular problems. There was lab work done, and the Rx management puts it over the top. You're good.

  7. #7
    Default Rx Drug Management
    Here is another scenario that is cause for thought and feedback....

    Medicare patient
    Sex; female
    Pain Scale: 4
    Pain location: Chest
    Surg Hx: Hysterectomy

    Allergies: Epinephrine, Furosemide, Tramadol

    Here for eval of chest pain. Hx of Coronary artery disease, RCA stenting in 2004. In the past week, she has had an onset of chest pain that began with a few twinges of pain lasting for a few seconds, underlying the left side. In the past few days this has increased to to involve sternal area as well. The pain does not feel like a pulling muscle. She took some Devocet with improvement of symptoms.

    She denies cough and dyspnea. There is no dysphagia or odynophagia. The pains are worse when lying on left side. No leg swelling. No calf pain or hemopytosis. She denies fever, chills, and PND.

    Current Meds: Cozaar, Plavix, and Darvocet

    Family Hx: Son and brother with MI; Mother with HTN.

    Social: She is a non-smoker.

    Phys Exam:
    General -- overweight, pleasant in no distress
    Neck: JVP not elevated
    Lungs: Clear to asculation and percussion. Respirations are unlabored. No chest wall tenderness.
    Cardiac: Rhythm is reg with normal S1 and S2 and 1/6 mid-systolic murmur at lower left sternal border. No radiation. JVP not elevated.
    Abd: soft and nontender. No mass. No aortic bruit.
    Extrem: Without edema. No calf tenderness.
    Chest: X-ray reviewed personally by shows normal heart size and clear lung fields. No change from 2005. EKG shows show normal sinus rhythm. rate 56, with no repolarization change. Toponin I is .03.

    IMPRESSION: Chest Pain. Suspect noncardiac pain, prob chest wall. Advised continued use of Darvocet. She was instructed in nitroglycerin use as trial. PHone follow in 48 hours. Possible Myoview test in future.

    My thoughts and questions: Can we code a EKG, for example, 93010? How about an Xray code? We have a partial EKG strip that has the doctor handwriting stating, "Normal EKG" and the doctor also signs the EKG strip machine strip and his interpretation. I feel that this is not enough to code a 93010 because we don't have the doc saying, "Interpreted by me" or anything like it. Bottomline: I would lean towards just a 99203 with 786.50.


  8. #8
    Default Rx Drug Management
    Brandi -- Sorry, I know it is Christmas eve...but where did you get Hyperlipidemia? I was looking for it.

  9. #9
    Smile Rx drug management and 99214
    Brandi -- I believe you. But for learnings sake, what are the 3 chronic conditions? And where did you get Hyperlipidemia? This knowledge might help me in the future...a lot.

  10. #10
    Exclamation
    Quote Originally Posted by fredcpc View Post
    Brandi -- Sorry, I know it is Christmas eve...but where did you get Hyperlipidemia? I was looking for it.
    I was trying to figure out what I was talking about when I told you that...turns out I can't. Ha! I must have gotten distracted and mixed up details from something else - Let me see if I can give a coherent answer this time...
    Okay, for Headache Guy:
    I see where the 3 chronic conditions came from - I got these: HTN, Type II Diabetes, PVC
    (ACTOS is a prescription medication used with diet and exercise to improve blood sugar (glucose) control in adults with type 2 diabetes.)
    And I think I meant to say hyperglycemia, and my brain locked on hyperlipidemia instead; I don't know why I was even thinking about it then, because he doesn't have it. But, his "poor glycemic index" is an indication of mild progression in a chronic condition, in addition to 2 stable chronic conditions. The only new problem is the headache, which is, apparently, a side effect of his HTN treatment. The lack of notation on the diabetes makes it seem like another doctor might be responsible for his diabetic management. If that's not the case, this doctor really needs to write more; but if it is, I'm not confident that the diabetes is significant in calculating this particular MDM.

    The notes have room for improvement (a LOT of room). I do see what you're saying about it being baffling, and I don't think a 99214 would hold up in an audit - There's literally barely enough documentation to support a Detailed history and Moderate MDM, and it's vague, disconnected, and it skips through an undetermined period of time. I also find the focus of the record odd - If I were in the doctor's shoes, I'd take better care to ensure that my involvement and intent were conveyed more decisively, so that neither could be misconstrued by anyone - whether in an audit or in legal proceedings.

    What's missing from the note is more interesting than what's in it. There's no indication as to why the patient had "tried a [higher dosage]" of metoprolol in the first place. Was it prescribed, or self-adjusted? When did the increase occur? When did he call the doctor about it? Since it was effective in treating his HTN and PVC, how are those conditions going to be affected by tapering off the metoprolol? Will an alternative therapy be needed, or has the patient spontaneously recovered enough to no longer require the use of prescription medications? Tapering the dosage so drasticly, with no apparent intent to continue with the treatment, is a medical decision that requires more elaboration to clarify the rationale behind it, in my opinion. According to Wikipedia, headaches aren't a side effect associated with Metoprolol; it's even indicated for the treatment of migraines. There's risk of serious side effects, but many of the identifying risk factors (especially for diabetics), like swelling of the extremities, weren't documented as reviewed - which is not to say that they weren't. It just seems irresponsible to omit so much relevant information. You'd be hard pressed to appeal an adverse determination with so little to go on.

    Anyways...don't put too much faith in me - I'm still learning things, myself, so I'm wrong about things all the time. I try to answer to the best of my knowledge, to find out where my knowledge needs to get better. (There's a breakdown of how I got Detailed Hx)

    Pain location: Headache *ROS Neurologic
    Pain Scale: 1 *Would be HPI severity if it were documented by the doctor, and not a nurse or other staff.
    Follow up on Headache and HTN. Chief Complaint

    Allergies: Adhesive, Metformin, Ace Inhibitors *Past History

    He tried increasing metoproiol to 150mg bid with increase in HA noted. *HPI Context or Assoc. Signs/Symptoms
    He called me by phone and I advised tapering metroproil down to current dosage of 50mg bid, which he has noted has helpd his HA to about 30 percent of prior severity. *HPI Modifying Factors and Severity
    He said at it worst the HA feels like "a whack on the head." *HPI Quality
    He does note that metropriol was also helpful in PVC Tx. *ROS CV, but it's a stretch.

    His glycemic index is poor. Fasting glucose is is around 140, pm glucose is 120-140. *ROS Endocrine

    Meds: Cozaar, Actos, Metroproli

    Phys Exam:
    GEn: Obese man in no distress
    HEENT: Temporal arteries nontender; Oropharnyx is benign.
    Lungs: Clear to asculation and percussion.

    IMpression: 1) Headache -- He is improved with with reduction of metroilol. Will continue to taper metroprioil by 50% every 10 days. Reassessment in a month.

    2) HTN -- See recommendations to taper off metroprioil. Reexam in a month
    Last edited by btadlock1; 12-24-2010 at 08:22 AM. Reason: atrocious grammar

Page 1 of 2 12 LastLast

Similar Threads

  1. Risk Adjustment Management
    By smithe3 in forum Employment General Discussion
    Replies: 3
    Last Post: 08-03-2016, 04:56 PM
  2. Rx drug management help!
    By Lyta2000 in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 01-07-2015, 08:44 AM
  3. Rx Drug Management
    By drhoads in forum E/M
    Replies: 3
    Last Post: 08-06-2014, 02:05 PM
  4. Prescription Drug Management - charts to determine the MDM
    By cpclori in forum Auditing General Discussion
    Replies: 3
    Last Post: 08-18-2012, 10:02 AM
  5. prescription drug management
    By coderforlife in forum E/M
    Replies: 0
    Last Post: 04-29-2010, 11:42 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.