# Rx Drug Management - Does changing dosage



## fredcpc (Dec 21, 2010)

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?


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## btadlock1 (Dec 21, 2010)

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.


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## fredcpc (Dec 21, 2010)

*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?


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## btadlock1 (Dec 22, 2010)

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)


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## fredcpc (Dec 22, 2010)

*Rx Drug Management*

THank you for your input, and I agree with your choice. What do you think about the medical necessity factor?


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## btadlock1 (Dec 22, 2010)

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.


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## fredcpc (Dec 22, 2010)

*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.


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## fredcpc (Dec 23, 2010)

*Rx Drug Management*

Brandi -- Sorry, I know it is Christmas eve...but where did you get Hyperlipidemia? I was looking for it.


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## fredcpc (Dec 23, 2010)

*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.


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## btadlock1 (Dec 24, 2010)

fredcpc said:


> 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 hyper_glycemia_, 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


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## btadlock1 (Dec 24, 2010)

For the second chart you posted -  I got a 99214, based on detailed history, Detailed or EPF exam (95 or 97), and moderate MDM. 

MDM - Amount/complexity of data reviewed - I got as Extensive (or high - whichever) - I counted Diagnostic lab, Diagnostic X-Ray, Ordered/reviewed old records, and Diagnostic medical procedure.
#Dx/Tx Options - Low - 1 chronic stable condition (CAD - unless it was cured - is that something that can be cured? I'm sure that's a completely stupid question to everyone else but me...) 1 new problem, not severe with good prognosis
Risk - I put as Moderate for Rx drug management (Darvocet)...Incidentally, how old is this note? I thought that was recalled recently...


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## fredcpc (Dec 24, 2010)

*Rx drug management and 99214*

Chart #1) I like your counting. Good food for thought. I am coming up with 99213 with 784.0 and 401.9. Det, Exp, Low. Right?

Chart #2 (Darvocet med): You are right, if it is established, it is 99214 with 786.50. Any other Dx codes you can think of? New pt, 99203. Do you feel this a new or established pt?

 I was also trying to figure out how, or if, I should code the EKG. I went around and around with this EKG thing. 

EKG: I have a partial EKG strip that appears to have been done in the Internal Med office; and a doctor note on the strip that said "normal EKG" and he signed it. I also have a short description of rate, rhythm and sinus under the "chest" part of the exam, as you saw. What do you think on this?

Take care and talk to you after Christmas.


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## btadlock1 (Dec 26, 2010)

Case #1 - I'm conflicted on the code assignment, but I feel that 99213 is the highest that could survive an appeal with the records, even though it "technically" qualifies for a 99214, with the absolute bare minimum allowed. I really feel that this case could easily secure a 99214, if not a 99215, with better documentation. As for the diagnoses, I could use a little direction, myself. I'd have to ask a few other coders in my office to look at this and give their two cents before I decided on anything, if this were mine to work. I think the headache should be primary, but I'm not sure whether this is coded as a poisoning or a side effect - the doctor doesn't ever come right out and _say_ that the medication was causing the HA's, but it's implied by his decision to taper it off. What's unclear to me, is whether the HA is a consistent side effect with this medication, or if it's only problematic due to the increased dosage.

I do think that the HTN and PVC should be coded - they're definitely relevant. A part of me also wants to code the diabetes and poor glycemic index as some sort of supplemental code - even though this doctor isn't treating the condition (as far as the note indicates), since it might be significant, but I'm probably wrong about that. 
As for the levels - Detailed History, Problem focused exam at best, and MDM as moderate, because of the # of Dx/Tx Options and Risk. That said, I don't think the records have enough substance to justify a 99214, which is odd, because it seems like the patient's condition has the medical necessity to support at least a 99214. I can't give you a definitive answer without consulting with others, though.

Case #2
 - Seems like an established patient to me, and the diagnosis as chest pain should be enough.
- I'd code the EKG with a 26 modifier. The doctor signing the strip with his comments is sufficient to prove he interpreted it. I don't know what code you should select (Don't have my CPT), but I can tell you that ours are generally 93000 when I see them billed. That doesn't mean that's the code you'd need, though, just a place to look.
- The rhythm falls under CV, but the rate and sinus I'm unsure of. I think that the rate is actually credited to constitutional, but only when billed with 2 other vitals, and even if the sinus is also one of those vitals (along with height, weight, etc.), there still weren't enough to qualify for the extra bullet by 1997 rules. Since the constitutional and CV systems are both clear elsewhere in the note, the rate and sinus don't add anything significant, by 1995 rules.


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## fredcpc (Dec 27, 2010)

*Rx drug management and 99214*

Aloha. btw, I live in Hawaii. Hope you had a great Christmas. 

On Case 1) On PVC, the sentence in HPI is "He does note that metroprolol was helpful for PVC treatment." The doctor does not mention PVC in his impression, but he does mention metroprolol there. Metroprolol is used to deal with high blood pressure and chest pain after a heart attack. But is all this enough documentation to code PVC? I wish it was, but it is stretch in any case. Like you I got a 99214, but I can't remember how I did it. Metroprolol could easily be a just a tx for HTN. 

After review, I am getting a Low MDM. I don't see the moderate unless you are adding in another diagnosis. This was a follow up on a HA and HTN. So where is the moderate?

Case 2) I agree with you, I think it is established patient, but how can I be for sure? Is there a strong reference to this being an established pt. I am leaning towards the 93000 EKG code for this encounter too. I know you don't need a modifier here, but still unsure of est. vs. new pt. thoughts??


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## btadlock1 (Dec 27, 2010)

Hawaii? I'm super jealous! I'm landlocked in west Texas. Nothin' but dirt, as far as the eye can see...

Anyways...

#1 - You may be right about the PVC. I only thought it was relevant because it is being affected by the Metoprolol. It was only barely mentioned, but then again, so was everything else. The doctor didn't even address how the Metoprolol was working for the HTN, which doesn't make a lot of sense to me. As far as the MDM - I'm probably giving too much credit in the #Dx/Tx Options area - the amount of documentation doesn't seem right for Moderate MDM, and the doctor kind of downplays the problem in describing the pain. If you're getting low, go with it. I'm getting moderate, though on both the Marshfield point system and on my audit tool (from Trailblazer Medicare - our local carrier). But, I am taking the PVC into consideration, since it's also a cardiac condition.
On the Marshfield chart - I gave 1 point for "self limited, minor problem"
I also gave 2 points for "Established problem, stable or improved - one for HTN and one for PVC. 
On my audit tool, I give one point to "each new problem for which the diagnosis or treatment plan is evident, regardless of the presence of diagnostic information"
And 2 points for "each new or established problem for which the diagnosis or Tx plan is not evident" (the minimum #of points in that category), because the Tx plan for the HTN really isn't evident - tapering off of the Metoprolol is to treat the HA, not the HTN. How the HTN will be treated without the Metoprolol isn't indicated. 

I should note that I'm not confident about either one - I think my results are too high.

#2 - The note doesn't explicitly say she's new, and the note "No change from 2005" about the x-ray implies that the doctor didn't have to request the record from someone else, so she's been there before. She's on 3 different prescriptions (at least 2 for chronic conditions) which require periodic visits, so she's been seen within the past 3 years, and the phrase "Advised Continued us of Darvocet" makes it seem as though the doctor is familiar with the prescription to me, since the dosage isn't mentioned. I also can't see a patient receiving long term care for cardiovascular problems, deciding to see a completely different doctor for chest pain, out of the blue; I'd think she would go to the doctor who is well versed on her history, and that she already trusts to manage her care - but that's just my opinion.


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