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My doctor is wanting to use over the medication to make his risk higher and charge a 99214. Eztablished patient and stable problem HTN. No labs or other complexity ordered or reviewed. He feels if he tells the patient to take 3 ibruprofen at a time instead of the usual 2. It should be considered RX drug management. Can someone tell me the rule for this type of situation?

 

[jdibble]

Ibuprofen is an over-the-counter drug. On the table of Risk, management options shows Over-the-counter drugs as a Low risk. For a moderate risk the option is Prescription (Rx) drug management. The doctor is not writing a script for the patient or managing a prescription drug when he tells them to take an extra Ibuprofen - so I would point that out to him.

Also to determine the MDM, if he orders no labs, tests or radiology and the only thing he is seeing the patient for is the stable HTN, he will only get 1 point for diagnosis/treatment options and no points for complexity/data reviewed. Therefore, with the Low risk this would only give him an MDM of straight forward - which would fall under a 99212!

Hope this helps!