Urology Coding Alert

Question: My provider sometimes tells patients to take ibuprofen or other commonly available over-the-counter (OTC) pain medications. Would this ever count as prescription drug management, even though the drug can be obtained without a prescription?

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Answer: Managing a patient’s dosage of an OTC medication like ibuprofen can be considered prescription drug management in some situations, including the following:

• The healthcare provider actively oversees and adjusts the patient’s dosage based on their specific medical condition and needs. This may happen if a patient presents with a condition requiring a dosage of pain medication that is higher than what is available OTC.
• The patient’s use of the OTC medication is part of a larger treatment plan that the healthcare provider has established, and the provider monitors the patient’s response to the dosage adjustments. For example, if a patient has an injury that requires surgery, but the surgery cannot happen for a few days, and the patient needs to ramp up and then ramp down the dosage to quell the pain but not put them at any additional risk during surgery.
• The healthcare provider is advising the patient on potential drug interactions with other medications, monitoring for side effects or complications, and ensuring the safe use of the OTC medication. Some ubiquitously available OTC pain medications, for example, are contraindicated by other medications or even lifestyle choices.

In such circumstances, the provider’s involvement and oversight of the patient’s OTC medication usage go beyond typical self-medication and might be considered prescription drug management. Evaluate the level of risk for medical decision making (MDM) as well to choose the appropriate evaluation and management (E/M) code(s).