I have a question in regard to prescription drug management for MDM purposes for cortisone injections administered in the office. I work in an orthopedic office and our physicians are frequently administering cortisone injections. Some our physicians feel the injections fall under moderate MDM. This would only be for the visits where they can bill an office visit for. I question if that is accurate because I was thinking it would fall under low MDM. That is because injections are billed as DME using HCPCS J-Codes and that falls under the low MDM. Also the medications used are pulled from what is already in stock in the office and not actually prescribed.
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Wiki Is an in-office injection considered prescription drug management?
- Thread starter dgromit75@hotmail.com
- Start date
thomas7331
Guest
Personally, I would classify a joint injection as a minor procedure for purposes of MDM. It's not really prescription drug management because the provider isn't creating a drug treatment plan that the patient will follow - it's just a one-time administration. And it's definitely not DME - J HCPCS codes are for drugs and have nothing to do with DME. Incidentally, the fact that a drug is taken from stock vs. prescribed makes no difference as the risk involved is going to be the same in either situation.
That helps, thank you
podcoder70
Expert
Great question! To determine e&m level, the drug used in an injection does not fall under the category of "drug management". To use this category to increase an e&m level, a prescription must be sent to a pharmacy, otc drugs do not count either. Also, the j drug codes are not billed as DME, they should be on the same claim as the injection code. Medical decision making is determined by the provider and backed up by their documentation. The level is determined based on risk OR total time spent that day in the care of that patient. If the provider is coding the level based on risk, they need to meet two of the following thresholds: 1. # and complexity of problems addressed, 2. amount and/or complexity of data reviewed and analyzed and 3. risk of complications and/or morbidity or mortality of patient management.
If a patient comes in for the first time with a complaint and decision is made to perform an injection at that visit that could qualify for #1 and #3 in the moderate category. One acute illness and decision regarding minor surgery. If the patient returns with the same condition and gets another injection, no e&m would be warranted.
If a patient comes in for the first time with a complaint and decision is made to perform an injection at that visit that could qualify for #1 and #3 in the moderate category. One acute illness and decision regarding minor surgery. If the patient returns with the same condition and gets another injection, no e&m would be warranted.
So the drug used in an injection would not fall under the category of "drug management"?? Is there documentation anywhere that states that?? I have a few providers that feel that cortisone injections are considered part of the prescription drug management category.
blaymon
Networker
I am a PA, CPC and CEMC. I have always considered an in office injection of medications such as Toradol, Zofran, Phenergan, Rocephin, and steroids as prescription drug management. What do others think?
I would consider this prescription management toward the E&M (if billable). I am not aware of any guidance that the prescription must be sent to a pharmacy. What if you were giving the patient a pill sample? I would consider that Rx management as well.
amyjph
True Blue
Good discussion. If the provider is being paid for the drug (J code) and the administration (e.g. 20610/20611), how can we also count that separately towards the E/M MDM? My opinion is I wouldn't call it prescription drug management. I go back to the work RVUs and credit already being given. They injected it at the time of service and monitored the patient pre and post procedure if we are only talking cortisone/joint injections. Again, it's a good discussion and I can see both sides of it. The separate E/M would also have to be billable in the first place and support a 25 mod.
Some reading material:
Best explanation here:
Drugs that are injected in the office are certainly of RX strength; however, the coding of the service rendered may prevent it from counting as RX management. CPT codes when the injectable is a procedural service and performed by an MD/NP/PA provider have the risk of the drug already allocated as part of the wRVUs of the provider. Injections administered IM/SubQ by ancillary staff can also be billed independent of an E&M, but they are represented by CPT codes with provider wRVUs that only reflect a supervision level of service of staff. Therefore, the risk of management of the drug (3rd column of MDM) has not been pre-allocated.
This one is a little odd:
Is an in-office injection considered prescription drug management?
Injections administered in the office are not prescribed via pharmacy; they are billed as DME using HCPCS J code. The patient is then observed for adverse effects by physician or ancillary staff as considered in the CPT® administration code; therefore, it is not considered part of the risk in medical decision making of an E/M code under prescription drug management.
CMS states: The term “administered” refers only to the physical process by which the drug enters the patient’s body. It does not refer to whether the process is supervised by a medical professional (for example, to observe proper technique or side-effects of the drug). Injectable drugs, including intravenously administered drugs, are typically eligible for inclusion under the “incident to” benefit. With limited exceptions, other routes of administration including, but not limited to, oral drugs, suppositories, topical medications are considered to be usually self-administered by the patient.
Drugs that are injected in the office are certainly of RX strength; however, the coding of the service rendered may prevent it from counting as RX management. CPT codes when the injectable is a procedural service and performed by an MD/NP/PA provider have the risk of the drug already allocated as part of the wRVUs of the provider. Injections administered IM/SubQ by ancillary staff can also be billed independent of an E&M, but they are represented by CPT codes with provider wRVUs that only reflect a supervision level of service of staff. Therefore, the risk of management of the drug (3rd column of MDM) has not been pre-allocated.
Some reading material:
Best explanation here:
Drugs that are injected in the office are certainly of RX strength; however, the coding of the service rendered may prevent it from counting as RX management. CPT codes when the injectable is a procedural service and performed by an MD/NP/PA provider have the risk of the drug already allocated as part of the wRVUs of the provider. Injections administered IM/SubQ by ancillary staff can also be billed independent of an E&M, but they are represented by CPT codes with provider wRVUs that only reflect a supervision level of service of staff. Therefore, the risk of management of the drug (3rd column of MDM) has not been pre-allocated.
This one is a little odd:
Is an in-office injection considered prescription drug management?
Injections administered in the office are not prescribed via pharmacy; they are billed as DME using HCPCS J code. The patient is then observed for adverse effects by physician or ancillary staff as considered in the CPT® administration code; therefore, it is not considered part of the risk in medical decision making of an E/M code under prescription drug management.
CMS states: The term “administered” refers only to the physical process by which the drug enters the patient’s body. It does not refer to whether the process is supervised by a medical professional (for example, to observe proper technique or side-effects of the drug). Injectable drugs, including intravenously administered drugs, are typically eligible for inclusion under the “incident to” benefit. With limited exceptions, other routes of administration including, but not limited to, oral drugs, suppositories, topical medications are considered to be usually self-administered by the patient.
- Can we always give a moderate level of risk using the example of “prescription drug management” when we order an injection for the patient?
Answer: Ordering an injection for the patient is not prescription drug management. There can be many different reasons for ordering injections including, but not limited to, birth control, cancer treatments, joint issues, allergies and antibiotics. The column of risk is “Risk of Complications and/or Morbidity or Mortality of Patient Management.” The MDM table includes examples of situations that could fall under that category of risk. The AMA definition of morbidity reads “A state of illness or functional impairment that is expected to be a substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.” The AMA definition of risk reads in part: “The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of event under consideration.” “Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified healthcare professional in the same specialty.” “For the purposes of MDM, level of risk is based on consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.” Choose the level of risk based on the physician or other qualified health care professional’s determination and documentation of the risk to that specific patient for that specific encounter for that specific treatment choice. Billing for the administration of the injection and drug show the decision for that treatment.
Drugs that are injected in the office are certainly of RX strength; however, the coding of the service rendered may prevent it from counting as RX management. CPT codes when the injectable is a procedural service and performed by an MD/NP/PA provider have the risk of the drug already allocated as part of the wRVUs of the provider. Injections administered IM/SubQ by ancillary staff can also be billed independent of an E&M, but they are represented by CPT codes with provider wRVUs that only reflect a supervision level of service of staff. Therefore, the risk of management of the drug (3rd column of MDM) has not been pre-allocated.
thomas7331
Guest
This is all kind of a moot point here because you only need one element to meet the level of moderate in the risk category. So if you count the ordering of the injection as prescription drug management, you have moderate risk, or if you count it as a minor procedure on the joint with identified risk factors, you also have moderate risk. There's not a lot difference made by deciding this question on way or the other.
One can often use more resources debating questions about E/M level than the benefit that is ultimately gained or lost by the outcome of the final decision.
mnuhfer04
Guru
I had listened to a podcast, I believe it was Terry Fletcher, and she mentioned that giving out samples is not considered prescription drug management. I should try to look for it again, I don't remember the reasoning behind it.
If that's true, I would love to know the reference and/or reasoning. The provider is making the same decision about risk whether they hand the patient a box, administer the medication personally (or by qualified staff), or transmit the rx to a pharmacy. The risk would only change if the medication is an OTC low risk medication.
briesgift22
New
Gator
Networker
This answer is directly from Medicare.
Q8. Can we always give a moderate level of risk using the example of "prescription drug management" when we order an injection for the patient?
A8. Ordering an injection for the patient is not prescription drug management. There can be many different reasons for ordering injections including, but not limited to, birth control, cancer treatments, joint issues, allergies, and antibiotics. The column of risk is "Risk of Complications and/or Morbidity or Mortality of Patient Management." The MDM table includes examples of situations that could fall under that category of risk. The AMA definition of morbidity reads "A state of illness or functional impairment that is expected to be a substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment." The AMA definition of risk reads in part: "The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of event under consideration." "Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified healthcare professional in the same specialty." "For the purposes of MDM, level of risk is based on consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter." Choose the level of risk based on the physician or other qualified health care professional's determination and documentation of the risk to that specific patient for that specific encounter for that specific treatment choice. Documentation in the medical record must support the decision for the treatment to bill for the administration of the injection and drug.
Q8. Can we always give a moderate level of risk using the example of "prescription drug management" when we order an injection for the patient?
A8. Ordering an injection for the patient is not prescription drug management. There can be many different reasons for ordering injections including, but not limited to, birth control, cancer treatments, joint issues, allergies, and antibiotics. The column of risk is "Risk of Complications and/or Morbidity or Mortality of Patient Management." The MDM table includes examples of situations that could fall under that category of risk. The AMA definition of morbidity reads "A state of illness or functional impairment that is expected to be a substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment." The AMA definition of risk reads in part: "The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of event under consideration." "Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified healthcare professional in the same specialty." "For the purposes of MDM, level of risk is based on consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter." Choose the level of risk based on the physician or other qualified health care professional's determination and documentation of the risk to that specific patient for that specific encounter for that specific treatment choice. Documentation in the medical record must support the decision for the treatment to bill for the administration of the injection and drug.
Gator
Networker
This answer is directly from Medicare.
Q10. I provided a sample prescription drug to the patient. Is this "prescription drug management"?
A10. This would be counted as "prescription drug management."
nolanspade
Networker
Was a prescription written? I try to take terms as literally as possible - the name is "prescription drug management."
nolanspade
Networker
I think we need to all step back and just take a literal look at the the topic - "prescription drug management" - though many of the drugs injected in our offices would require a prescription if ordered for home use, we are not managing these injectables - telling the patient how to use, what not to take with it, how long to take it, when to take, coordinating with other providers, checking interactions for new medications ordered by other doctors for a chronic meds you manage etc - and, we're also not writing a prescription. I know that may sound very silly of me, but when you send a patient home with a prescription, I believe (I could be wrong) the risk of the patient misusing (intentionally or not) the drug, or unexpected side effects or allergies (like a sulfa? yuck!) while not in a clinic where immediate care is available, the risk is greater than giving an injection in the office when you can monitor the patient condition and outcome.
I used to get hung up on these scenarios because I would read too much into things, and had to learn to step back and take literally what the words are saying to me. An example of literal interpretation substantiated by this guideline: CPT 2024 pg. 8 "options selected and those considered but not selected." I say "Decision for major surgery" if a decision either way is made, it counts, as long as it's documented correctly.
That's how I see it, and it's been working for me, has gotten me out of overthinking things for sure.
I used to get hung up on these scenarios because I would read too much into things, and had to learn to step back and take literally what the words are saying to me. An example of literal interpretation substantiated by this guideline: CPT 2024 pg. 8 "options selected and those considered but not selected." I say "Decision for major surgery" if a decision either way is made, it counts, as long as it's documented correctly.
That's how I see it, and it's been working for me, has gotten me out of overthinking things for sure.
blaymon
Networker
Not everyone will agree on this topic and that is okay. Providers are still managing these injectable medications in the office. We have to review the patient's chart for allergies, current medications for possible interactions, comorbid conditions and sometimes recent lab work before I order it. There is also risk of infection, improper placement of the injectable medication (such as in a blood vessel or bursa) to worry about. For some diagnosis such as a vaginal yeast infection, the most common treatment is prescribing Diflucan which is one tablet and that is it. I compare that to ordering Toradol in the clinic which can have devastating effects on the kidneys in some patients. The risk is much higher with the injectable Toradol than prescribing Diflucan for a yeast infection. I am not saying I am right but there is considerable risk with injectable medications.
Gator
Networker
This question was answered directly by Medicare.
Q10. I provided a sample prescription drug to the patient. Is this "prescription drug management"?
A10. This would be counted as "prescription drug management."
podcoder70
Expert
Per Noridian: Prescription drug management does not require a new drug, a new dosage, or a discontinuation of a current prescription. The medical record will show the physician work to determine the medical necessity of the prescription drugs. An encounter documented as only a prescription refill without documentation of a problem addressed would not suffice. The AMA defines a problem addressed in part as "A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service." You can also count prescription medications considered but not given could be patient choice, possible drug interactions, etc. Prescription drug management does not include drugs injected during the current or subsequent encounter
Agree!