Wiki OTC Prescription Increasing Coding

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Sarahp941

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We are a Dermatology office using EMR software. Prescription and Prescription Management was programmed as "Moderate" risk. I am now finding my Providers using Prescription for OTC meds, whether insurance covers them or not. But by using this plan with a chronic condition, it pulls a level 4. I am trying to find documentation or information on this grey area. Many articles I read say the Provider's discretion on whether the medication is considered Low or Moderate risk, based on chronicity of the diagnosis. But of course when you leave it to a Provider, they don't always document properly or they think everything is justified because they "prescribed" something. CMS says " "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. Credit is given if the documentation clearly indicates medical decision-making took place regarding the medication(s). This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage." But nothing is talked about for OTC drugs. Our patients may have skin redness or xerosis and we order/recommend Dermend or Amlactin lotion, which is OTC. But since we documented the prescribing portion, it counted towards management. I am confused and other posts I have seen throughout this forum are also not clear. Any help is greatly appreciated! Thank you.
 
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From a everything I've read, "prescription drug management" means just that, prescription drugs. OTC medications do not count towards that no matter what the provider documents in the record.

Tom Cheezum, OD, CPC, COPC
 
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I'm with Dr. Cheezum here. OTC meds (regardless of where in your EMR the physician documented them) would be considered low risk, not moderate risk. I couldn't dispute an auditor with a straight face and try to justify moderate risk for Amlactin for skin redness. Same level as a COPD with DM II patient getting a minor procedure??
 
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I think the confusion comes from OTC medications that the Pharmacy will fill. Maybe for insurance coverage? Not sure? But my thought is, either way, the risk is low as the medication is OTC and we are not continuously monitoring for dry skin. When I questioned the documentation, my Provider responded this: "I am prescribing a medication, whether it is sent to a Pharmacy or physically handed to the patient to grab in a department store. There is a chronic condition (Xerosis), and a specified treatment regimen for the patient to follow. That should justify a level 4." But again, it's Xerosis and the medication is lotion.

***Thank you both for your feedback.
 
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Risk is what is being leveled here.
From the AMA 2021 E/M guide:
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.

Unfortunately, the current AMA guide does not give examples of low risk, but OTC was historically always low risk. I think I read some MAC advice that OTC meds are still low risk, but I don't have that reference. Maybe you could argue moderate risk if it's an OTC med that the patient is having some issue with - the provider needs to adjust how often/how much it is used. Maybe. Or if the provider thought the redness was due to an acute allergic reaction causing difficulty breathing.
But apply Amlactin to affected areas of dry skin BID without some other factors, I just don't see how you could get to moderate. The example is "prescription drug management." Amlactin is not a prescription drug.

I did find this AAFP reference:
If you are billing based on MDM, you can include decisions about prescription medications, but over-the-counter (OTC) medications generally don't meet moderate complexity. If you use OTC medications in that context, just state why the decision was higher risk. A prescription for an OTC medication for insurance coverage purposes does not meet this threshold.
 
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It doesn't matter whether the patient picks the OTC med up from a display counter or the pharmacist gives it to the patient.If its OTC, its low risk. An example I've run into as an eye doc: I would often recommend OTC artificial tears for dry eye to patients. Many of my military retirees could get this from the pharmacy at the local Naval hospital. However, the pharmacy there required that I write out a full prescription with name, quantity and instillation instructions.

Also, there are several decongestants which are kept behind the pharmacy counter. They're OTC but the patient has to have the pharmacist give them the box, partly because of use of some of these to manufacture meth but also because some were contraindicate for patients with HT.

Tom Cheezum, OD, CPC, COPC
 
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And yet I received an answer to my question recently on OTC vs Rx: Increased dosage, or prescription only, is moderate risk. Like a certain dosage of Ibuprofen not available OTC because of increased dosage-- usually measured in milligrams.
I can see this as moderate especially in the case of chronic kidney disease or ESRD where ibuprofen can affect kidney function.
 
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