# Medical Necessity -vs- Prescription Drug Management



## fowens (Sep 25, 2012)

Hi all, I need help with a coding debate...  

We all know that medical necessity is the over-arching criteria for selecting codes... My question is regarding prescription drug management and how this plays into medical necessity. 

Here's the scenario: An otherwise healthy 30 year old presents with a sore throat to their PCP for established acute visit.   They present with sore throat and are given a strep test that is positive. An simple antibiotic is written. A detailed history and expanded exam is performed.

The presenting problem even though it is new is uncomplicated so medical necessity should direct the provider toward low decision making. Which so far in this case would support a 99213.  So does counting prescription drug management for writing a Rx for an antiobiotic alone justify a 99214 for this type of visit?

Do we automatically count Prescription Drug management every time a Rx is written without regard for medidcal necessity?  Is there anything in writing that defines prescription drug management when it comes to risk?


----------



## LLovett (Sep 26, 2012)

Why is it "uncomplicated"?

The presenting problem column of the table of risk is what I am assuming is behind the thought that this is uncomplicated. But the table of risk itself tells you to use the highest level of risk that the visit qualifies for. In this case it is the Rx management. It is a new problem either no additional work up, 3pts, or if they sent off for cultures with work up 4pts. This is moderate medical decision making. 

I totally disagree with calling any Rx drug "simple". I have personally been misdiagnosed with strep and prescribed PCN. That was how we learned I was allergic to PCN and they almost killed me. I was 20 and healthy at the time. Just because we see scripts written a lot doesn't lessen the fact that these drugs require a prescription for a reason.

Getting off my soap box now,

Laura, CPC, CPMA, CEMC


----------



## fowens (Sep 26, 2012)

You're right, I understand there is risk with meds given. Yes, when I said uncomplicated I was talking about the presenting problem;  but Dr's themselves will bill low level visits based on the presenting problem even when they give a med that doesn't have a "known risk" those meds I guess are what I would call simple.  Of course all meds have some risk, and I'm not saying that it shouldn't be counted, but should it prompt the Dr. to bill a higher level every time?  Also, my coding example should have said sore throat with _no confirmation of strep_ and no clinical documentation that infection was present.

So I guess my real question is.... when auditing a Dr. visit note; if he bills a 99213 for one of these simple presenting problems with no labs or xrays do you tell him he under-coded and should have billed a 99214 even though he didn't document anything other than a Rx? Or do you advise the Dr. he billed appropriately based on medical necessity?


----------



## trudel@smsc.org (Mar 27, 2014)

*strep is no joke*

Strep is no joke! And certainly complicated. If strep goes untreated, it can cause other organ damage and could cause death. Every time I code where Strep 034.0 is dx, It is always a moderate risk and most times a new problem.


----------



## dtlandry67 (Mar 28, 2014)

I disagree that a visit for Strep w/an antibody prescribed is always a moderate risk.  Putting aside the fact that yes, all drugs carry risks, a lot of providers are getting dinged for this.  My MAC (first coast) had this in a Q&A:

Q. What is required to get credit for prescription drug management? Do I have to stop, start or change a medication dosage, or can I get credit for making the decision to continue a specific medication?
A. Credit is given as long as the documentation clearly indicates that decision-making took place in regard to the medication(s).

In most straightforward Strep cases (with nothing else going on at that episode of care) you are looking more at a Low level MDM.


----------



## Pam Brooks (Mar 31, 2014)

Although we do consider Rx drug management in the table of risk to help quantify MDM, we also have to consider the nature of the presenting problem as it relates to the overall patient care.  

In this case, the otherwise-healthy 30 year old presents with strep.  The typical treatment for this straightforward strep is an ABX, and there are no other issues/comorbities, etc., to consider this any more than a low-level visit.    

With regards to complications due to medications....we have to be careful as auditors to retain some objectivity when coding.  Although we may have had a bad experience in healthcare, we can't allow that to cloud our judgment when it comes to auditing.  It's important to understand what can happen, but unless it's documented as being a potential issue...it didn't happen.


----------



## MnTwins29 (Mar 31, 2014)

dtlandry67 said:


> I disagree that a visit for Strep w/an antibody prescribed is always a moderate risk.  Putting aside the fact that yes, all drugs carry risks, a lot of providers are getting dinged for this.  My MAC (first coast) had this in a Q&A:
> 
> Q. What is required to get credit for prescription drug management? Do I have to stop, start or change a medication dosage, or can I get credit for making the decision to continue a specific medication?
> A. Credit is given as long as the documentation clearly indicates that decision-making took place in regard to the medication(s).
> ...



This made me think of another common scenario on a follow-up visit and the patient should "continue" medication X.   What constitutes "decision-making"?  Condition Y is well-controlled with medication X, so continue?   Pt is requesting refill?   Talk about a grey area!


----------



## dtlandry67 (Apr 3, 2014)

I agree Lance it is very grey and we are given just enough guidance for it to be interpreted many different ways!

If, for example, its a refill on a cholesterol or thyroid med I will look to see if they reviewed or ordered a lab and decided the dosage is right then I may give them credit as it shows MDM.  Getting the physicians to expand on their documentation in A/P helps here also especially if they document any side effects the patient may be having or they advise them on risks or possible side effects.  

If it is just a one time med for an acute problem (like the strep) then I may not give them credit.

It all comes down to the documentation.


----------



## JillSmithers (Jul 23, 2014)

I think you are putting too much subjective decision making into it. That is why we have the MDM guidelines. If it "adds" up to a 99214, by following the table and guidelines, then let it be a 99214. I think we as coders, overthink things and start making decisions that are best left to the physicians. just my two cents...


----------



## a.montaruli@gmail.com (Jul 23, 2014)

Unfortunately, medical necessity is not up to the coder. If it looks and smells like a 99214, it is a 99214. Prescription drug management is a moderate risk level which is often confused with the overall MDM level.


----------



## mchambers1279 (Nov 22, 2019)

I don't agree with some of the comments here. I feel like with the EMR. all Physicians can get a level 4 on most everything. A coder can't just go by a coding tool. and, if you do then you are at risk of a huge audit when your practice turns in 85% 99214 just because they gave a medication. I feel like management of medication in general should be managing it for a long term problem. Where there are substantial risk involved. Because really what they are managing are the effects it will have on the patients presenting problem. Is the provider really managing a medication for a person that came in with a simple UTI, just because they gave the person an antibiotic. This was a huge fail in my opinion and left room for Audits. A family practice Doc gives medication to all most every person that walks in the door. So if they have templates set up for History and Exam, They are already at a 99214. I feel when you get down to the bottom of the coder. You should ask yourself? Was the documentation in the chart pertinent to the presenting problem. After all, what was the intention for the visit that day?
In other words did they really need to do a detailed exam for a UTI? or should it have been problem focused? or even EPF? Did you really need a 10 point review of systems? or is it just in a template? For me, the EMR has made it much more difficult to code. Maybe I am oriented to this direction because I have a nursing background. I don't know. Its hard to say who is right or wrong. But when CMS audits they will take money back. They are looking at what others are coding around you. Be careful coders.


----------

