MDM -Prescription Drug Management

[pfeldner]

The E/M Risk guidelines state: "The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment".

When a prescription drug is given PO in the ER, does this count as "prescription drug management"? The MD is using the drug to treat the patient during the visit but is not writing a prescription for the drug after the encounter.

[btadlock1]

The E/M Risk guidelines state: "The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment".

When a prescription drug is given PO in the ER, does this count as "prescription drug management"? The MD is using the drug to treat the patient during the visit but is not writing a prescription for the drug after the encounter.

Yes it counts - Rx drug management is the use of any Rx drug, either while in the office, or one that the patient picks up at the pharmacy. A prescription drug has to be written by a doctor and administered by a pharmacist, because it has the potential to be stronger, more complicated, and/or more dangerous than OTC drugs. There's a higher risk of an adverse reaction, or complication involving other medications that the patient may be on, so any use of an Rx drug requires a degree of MDM.

That said, be careful not to bump a whole E/M level up based solely on the fact that an Rx was mentioned; some situations don't necessarily warrant a higher level of E/M simply because a prescription was given, and this area of E/M has a tendency to produce a falsely-high result. Use your judgement in assigning the overall level, and only assign the level that is supported by medical necessity, in the event that the documentation adds up to a high level code every time. Use the clinical examples in Appendix C of the CPT book to guide you. Hope that helps!