Medicare Compliance & Reimbursement

Question: I am looking for assistance on this. I have a provider who has stated that if he recommends that a patient take OTC meds at prescription strength, such as Ibuprofen, this qualifies as "moderate" for decision making. I am looking for some guidance on this.

Answer: Moderate decision making involves other factors besides the level of risk. In the typically applied carrier audit grid, there are three components that determine MDM. The number of diagnostic and management options, the amount and complexity of data, and finally the level of risk. He is correct that recommending prescriptive therapy can be moderate risk. However, at least two of the areas of MDM must be supported in order to qualify for a given level of MDM complexity. So you have to score all three components of decision making: Risk (here prescriptions are moderate risk), number of diagnoses and management options, and data.

In order to get to moderate MDM, you need to meet or exceed the criteria in two of the three areas. Most providers typically write actual prescriptions for prescription strength medications to make sure the directions are formally made and clear. Just to clarify, though, it's the dosage that determines whether certain medications are "prescription" medications, since that's the source of the risk. The risk isn't from the act of simply filling out an Rx form (such as for a surgical donut) -- nor does it come from the act of a pharmacist dispensing the medication.

In other words, an order for 600 mg of ibuprofen is an order for prescription medication, regardless of whether the pharmacist dispenses one 600 mg pill or the patient is instructed to take three 200 mg caplets.