EM Coding Alert

Question: Our pediatrician gave a patient a trial/sample medication. The doctor documented instructions and medical necessity in the patient’s record. Does this qualify as moderate risk for prescription drug management?

AAPC Forum Participant

Answer: The fact that the pediatrician gave the medication to the patient as a sample instead of as a prescription does not alter the medical decision making (MDM) risk level, providing the pediatrician monitors the medication’s effectiveness in treating the patient’s problem.

The moderate risk of morbidity from treatment MDM level is for prescription drug management (emphasis added). Additionally, risk is determined not by the specific treatment the provider recommends, but by the thought process the provider undergoes to arrive at the decision of whether a specific medication is effective in treating a specific condition.

So, assuming the pediatrician has not simply given the patient a sample for a one-off condition (for example, the pediatrician gives the patient a sample of acetaminophen because the patient complains of muscle aches), you can assign a moderate MDM risk level in this situation. But in addition to documenting that the drug is being ordered to treat a specific condition (the medical necessity you mention), the pediatrician must document following through with the patient to see if the medication is effective (or not) over a determined course of time in the management of the patient’s condition.