Wiki Refilling Prescriptions

[KaylaRieken]

What do most of you give for refilling prescriptions? 99213s or 99214s? We have patients that are on medications for BPH, or elevated PSA, or Overactive Bladder, sometimes a medication for all three of them. Patients come in every 6 months or every year and they are refilling meds.

 

[thomas7331]

There is no way for me to answer this question - I have never chosen or even estimated a code just based on limited information. It is not possible to correctly assign any particular code level just for refilling prescriptions - that is only one minor component of an E&M and the level has to be based on all of the components in the documentation, i.e. presenting problems, history, exam, MDM and time. Even knowing the diagnosis, you would still have to consider whether or not these are stable problems, and how extensively the provider evaluates them at the time the patient presents for a refill. Every patient is unique and the code has to be appropriate for that individual situation.

 

[KaylaRieken]

Most of the time its a comprehensive HPI, and comprehensive exam, and stable problems. They are reviewing a psa, ua, and bladder scan,