Prescription Drug Management

[Adam Smasher]

Few things brighten my day like a level 4 e/m, and "prescription drug management" is one of the easiest ways to get there. Obviously, there's more to a level 4 e/m than writing a Rx. But I haven't found a clear definition of "prescription drug management" and I have to imagine there's more to it than the singular act of prescribing some of the really innocuous drugs we prescribe as podiatrists. I did find one billing memo online for emergency docs says you have to review pt's current meds.

So here's a list of drug prescribing scenarios, and no I don't treat all of them as "moderate risk complexity." Let me know your opinions, would these be considered **by an insurance auditor** to be moderate risk? Low risk? Straight forward? Not an e/m at all?

1) pt comes in for the 9-week special, complaining of progressive worsening burning nerve pain. After reviewing the pt's meds and state prescription database, you rx gabapentin 300 tid.

2) same pt returns 9 weeks later, feeling much better. You review their med list, state database, and refill their gabapentin at the same dose (decision to maintain rx dosing)

3) pt complains of Achilles tendinitis, you rx Naproxen 500 bid (prescription strength dosing of otc med)

4) Achilles tendinitis pt wants topical, you rx Voltaren gel so insurance covers it (rx topical NSAID which is still cleared in the kidneys)

5) DM pt with Tinea Pedis, you rx topical antifungal so their insurance will cover it (this is barely a drug, but it has a MOA, plus there's an ever so small chance it can prevent skin fissuring leading to ulcer/infection)

6) DM pt wants rx cream, wants insurance to cover it, you prescribe Amlactin

7) same pt wants refill of Amlactin

8) rx Santyl ointment for an ulcer

9) rx regranex for am ulcer, knowing full well you'll have to fill out a prior auth (maybe bill for time instead?)

10) rx triple antibiotic ointment for a wound, which can be purchased at the dollar tree, but you don't trust the pt to do it on their own so you involve the pharmacy

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[dtrack22]

In most of those scenarios, it is not the Rx that affects the complexity as much as it is the dx/problem points. Reviewing meds and Rx’ing anything that isn’t commercially available should hit “therapeutic drug management” criteria. But when they are f/u and stable, the refill Rx isn’t going to be relevant when you don’t have the problem points to get to a level 4 any ways.

 

[Hybrocure]

1) pt comes in for the 9-week special, complaining of progressive worsening burning nerve pain. After reviewing the pt's meds and state prescription database, you rx gabapentin 300 tid.

2) same pt returns 9 weeks later, feeling much better. You review their med list, state database, and refill their gabapentin at the same dose (decision to maintain rx dosing)

Wait this happens? They feel better after gabapentin? I rarely rx it because these patients already come in on max dose

 

[air bud]

Wait this happens? They feel better after gabapentin? I rarely rx it because these patients already come in on max dose

Gabapentin is amazing. They either aren't on it or are on like 100mg tid from PCP. Made countless lives better with gabapentin.

 

[Adam Smasher]

In most of those scenarios, it is not the Rx that affects the complexity as much as it is the dx/problem points. Reviewing meds and Rx’ing anything that isn’t commercially available should hit “therapeutic drug management” criteria. But when they are f/u and stable, the refill Rx isn’t going to be relevant when you don’t have the problem points to get to a level 4 any ways.

Thank you for not answering the question which was to what level of risk complexity do these scenarios rise if anything. Often times you don't have the dx/data complexity for a level 4, but sometimes you do, especially when you see someone who wants this that and the other problem worked up, and the rx might push you over the top.

 

[Adam Smasher]

Wait this happens? They feel better after gabapentin? I rarely rx it because these patients already come in on max dose

Gabapentinoids (as well as opioids) are a volume knob, not an on-off switch

 

[HardRoadPaved]

So here's a list of drug prescribing scenarios, and no I don't treat all of them as "moderate risk complexity." Let me know your opinions, would these be considered **by an insurance auditor** to be moderate risk? Low risk? Straight forward? Not an e/m at all?

Bingo... the category or examples of moderate risk could include "prescription drug monitoring". So the risk still has to be there. Let's go thru your examples below

1) pt comes in for the 9-week special, complaining of progressive worsening burning nerve pain. After reviewing the pt's meds and state prescription database, you rx gabapentin 300 tid

4

2) same pt returns 9 weeks later, feeling much better. You review their med list, state database, and refill their gabapentin at the same dose (decision to maintain rx dosing)

4

3) pt complains of Achilles tendinitis, you rx Naproxen 500 bid (prescription strength dosing of otc med)

3 (healthy with no risk from the drug) or 4 (on BP meds, kidney concerns, GERD interaction)

4) Achilles tendinitis pt wants topical, you rx Voltaren gel so insurance covers it (rx topical NSAID which is still cleared in the kidneys)

3 since the drug risk is low enough drug is OTC; most insurances these days have started to reject 1% diclofenac

5) DM pt with Tinea Pedis, you rx topical antifungal so their insurance will cover it (this is barely a drug, but it has a MOA, plus there's an ever so small chance it can prevent skin fissuring leading to ulcer/infection)

3- there is no real risk or toxicity, just if it works or doesnt

6) DM pt wants rx cream, wants insurance to cover it, you prescribe Amlactin

Xerosis does not have any risk nor does the medication.

7) same pt wants refill of Amlactin

8) rx Santyl ointment for an ulcer

well I hope you're doing a lot more in that visit than its an ulcer heres santyl. You have a whole work up along with risk to patient. Also you made choice to do enzymatic debridement... what led you there?

9) rx regranex for am ulcer, knowing full well you'll have to fill out a prior auth (maybe bill for time instead?)

While sitting at your fancy steak dinner courtesy of S&N, then its worth it. same reasoning as above.

10) rx triple antibiotic ointment for a wound, which can be purchased at the dollar tree, but you don't trust the pt to do it on their own so you involve the pharmacy

same issue. the drug itself doesnt carry risk per se to the patient but the medical treatment does. Triple Abx oitment is an antibiotic so why are you prescribing it? Did you take a c/s? x-ray?

 

[Adam Smasher]

@HardRoadPaved

Thanks for your thoughts. Obviously those are not full and complete clinical vignettes and few if any patient encounters begin and end with the Rx. However where the rubber meets the road is in an insurance audit, I imagine the person who actually does this is basically a robot who may very well treat all Rx the same.

 

[dtrack22]

Thank you for not answering the question which was to what level of risk complexity do these scenarios rise if anything. Often times you don't have the dx/data complexity for a level 4, but sometimes you do, especially when you see someone who wants this that and the other problem worked up, and the rx might push you over the top.

I did answer your question. Anything that isn’t a commercially available medication should count as therapeutic drug management. That means your examples with OTC meds are very unlikely to be level 4, and some of your examples with prescription drugs where you aren’t hitting problem or data points, are also not level 4. Like the f/u gapapentin patient.

Onychomycosis isn’t a level 4 visit just because you Rx terbinafine. There have to be additional problems you are treating or you need to have reviewed (or stated you reviewed) some previously ordered labs/notes to hit medium complexity.

 

[Jummy Biffett]

Not to derail, but what about using time to determine level of E/M code? With the updates including face to face time, coordination of care, documentation on day of visit etc. it shouldn't be too difficult to hit 30 minutes on an established patient right? By definition that's a 99214. I'm not saying for every follow-up but for those time-suck appointments it seems appropriate.

 

[HardRoadPaved]

Onychomycosis isn’t a level 4 visit just because you Rx terbinafine. There have to be additional problems you are treating

So on its own this isn't a chronic disease with exacerbation

or you need to have reviewed (or stated you reviewed) some previously ordered labs/notes to hit medium complexity.

Simple.... Biopsy culture for one data point and path of the nail for another. LFTs another...

Thanks to certain labs that will protect us from terbinafine residence🤣

 

[air bud]

30 mins is not hard.

Not to derail, but what about using time to determine level of E/M code? With the updates including face to face time, coordination of care, documentation on day of visit etc. it shouldn't be too difficult to hit 30 minutes on an established patient right? By definition that's a 99214. I'm not saying for every follow-up but for those time-suck appointments it seems appropriate.

Remember this includes time reviewing, doing your note, talking to other providers etc. All the day of the visit.

 

[air bud]

As stated many times....so much easier to bill when in a MSG....I click on a button see referral note, review previous lab, order new lab.....drug MGMT..boom shaka laka.

Just know the rules and this stuff is lnt that hard ...

you want to renal dose a medication and need to talk to outside provider.....

....Social determinants of health increase risk

Patient is a poor historian and need to use outside source....

There is one chart and you should know every word on it.

 

[Boba Foot]

Remember this includes time reviewing, doing your note, talking to other providers etc. All the day of the visit.

What about the time I make the patient sit there waiting because I’m reading SDN?

 

[air bud]

What about the time I make the patient sit there waiting because I’m reading SDN?

Well that overlaps with the time that you are waiting for your Bros to text you back because you had to message them and ask them what to do about this patient cuz you haven't seen this before or don't know what to do.

 

[Adam Smasher]

So here's a list of drug prescribing scenarios, and no I don't treat all of them as "moderate risk complexity."

That means your examples with OTC meds are very unlikely to be level 4

Ok we agree then, but the question wasn't "are these level 4 e/m services?" The question was "do these prescriptions constitute prescription drug management for the purpose of determining risk complexity?" In fairness to you, most of us aren't interested in answering the question either.

Anything that isn’t a commercially available medication should count as therapeutic drug management.

That's a reasonable standard, but is it based in any published guidelines or just your opinion? Also 500mg Naproxen isn't commercially available. Neither is santyl.

 

[air bud]

I think the bigger thing is to also talk about those risk factors. Like I reviewed their bun creatinine we discussed risks associated with blah blah blah. Patient has no history of stomach ulceration, has not been told not to take NSAIDs by primary Care....Again we're talking about risk management.

Every note of mine says exactly what I did. I reviewed the referral note. I reviewed their most recent A1C which was blah blah blah. I reviewed multiple past cmps which demonstrated buen creatinine within normal limits, I reviewed recent x-ray which I independently evaluated..... Again much easier to do when you have easy access to all this stuff and how you Bill higher level visits.

Like everything, think out loud on paper. You can bill whatever you want it's just if you get audited you have to back up what you did.

 

[heybrother]

E/M Changes for 2021: The Beginning, Not the End

The E/M coding revisions aren’t perfect, but they represent a huge step forward in reducing physicians’ documentation burden, audit risk, and complexity of code selection.

www.aafp.org

https://namas.co/wp-content/uploads/2022/10/Modifier-25-RX-Management.pdf

I'm still looking for something specific like from a MAC.

 

[dtrack22]

That's a reasonable standard, but is it based in any published guidelines or just your opinion? Also 500mg Naproxen isn't commercially available. Neither is santyl.

From the MAC that covers FL:

A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”

Novitas says:
“Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.”


I think any dose of an OTC med that requires a prescription can be argued as meeting prescription drug management criteria, but I wouldn’t be shocked if payments got clawed back if audited. 500mg naproxen is not available to patients at that dose…but they can take 500mg of naproxen twice daily without your prescription. OTC medications are “low risk” according to the FDA and have always been treated as such in e/m guidelines and publications. So, the better question might be, why is your 500mg Naproxen prescription (which is listed as a therapeutic dose for adults on the Aleve bottle) increase the risk, and therefore the complexity, compared to a patient who is taking or you recommend take OTC naproxen? I would argue it does not. But all the MACs say is that at minimum it must be a “prescription drug.”

Here’s another way to look at it. Technically, maintaining a dose is prescription drug management. So a patient comes in and says “I bought a bottle of ibuprofen and take 800mg of ibuprofen 3 times per day.” And you recommend they continue taking the medication. Is that prescription drug management? It’s 800mg. You’re continuing the dose. They bought the bottle over the counter and take 4 pills at once. What is the difference in “risk” of therapy between that scenario and one in which you prescribe 800mg tabs? Is it just the fact that you sent in a prescription for it? Does that fact actually change the “risk” of the therapy?

 

[Adam Smasher]

What is the difference in “risk” of therapy between that scenario and one in which you prescribe 800mg tabs? Is it just the fact that you sent in a prescription for it?

One difference is that the rx is the doctor's imprimatur on the pt's use of the drug. The risk to the pt is equal in both cases but the doctor now assumes the long term medical legal risk for side effects, complications, refills, and ultimately discontinuation, and maybe that entitles the prescriber to a few extra bucks up front.

But all the MACs say is that at minimum it must be a “prescription drug.”

So what constitutes a "prescription drug" in the context of billing then? 500mg Naproxen is at least as much of a prescription drug as santyl. It's completely arbitrary. I take an absurdist view of billing, that there's no underlying logic or moral framework to any of it. Any pitch that can get past the umpire is legal.

 

[HardRoadPaved]

So lets also still not forget that "risk" is just one category of MDM.

You still need problem type or data reviewed.

With that in mind, someone coming in for an ankle sprain that you give naproxen 500mg for doesnt get you there. Still need to accompany a problem that has severity to test/interpret and "Risk of Complications and/or Morbidity or Mortality of Patient Management."

 

[HardRoadPaved]

Any pitch that can get past the umpire is legal.

Couldnt agree more. As long as your note creates that throw then you framed that "pitch" well. Your MAC is paying some low brow non-medical person to read your notes. So as long as your buzz words (risk, complication, order, review coordinated care) are there, you'll get a strike every time.

 

[Adam Smasher]

So lets also still not forget that "risk" is just one category of MDM.

You still need problem type or data reviewed.
View attachment 376538

With that in mind, someone coming in for an ankle sprain that you give naproxen 500mg for doesnt get you there. Still need to accompany a problem that has severity to test/interpret and "Risk of Complications and/or Morbidity or Mortality of Patient Management."

Review ER note, review XR, review XR report, word salad something something

 

[air bud]

Review ER note, review XR, review XR report, word salad something something

It's not so much review the report. If you didn't take it you need to offer your own opinion on what you independently evaluated, not just saying you reviewed something.

 

[dtrack22]

So what constitutes a "prescription drug" in the context of billing then? 500mg Naproxen is at least as much of a prescription drug as santyl. It's completely arbitrary.

Like I said, I don’t think there is anything wrong with claiming that anything you send an Rx in for is prescription drug management. The difference between naproxen and santyl (as drugs in general) is that the FDA has declared one low risk/safe for people to purchase at Walmart while the other still requires a prescription. Your defense for counting naproxen towards moderate complexity is that the dose you are prescribing is “prescription strength.” Which will all know is a load of crap, but if it gets you paid more, go for it. I just wouldn’t be surprised if there came a day where the feds or a commercial insurer asked for some money back for all of the level 4 visits where you prescribed bacitracin or ibuprofen for your patients.

It's not so much review the report. If you didn't take it you need to offer your own opinion on what you independently evaluated, not just saying you reviewed something.

Correct. And we all know that many times in PP you don’t have access to any of those things to even review. You also have to remember that what you are reviewing needs to be pertinent to the condition you are treating. So the thyroid panel that the PCP ordered and had in the referral note, isn’t something you can review in order to get data points for an ankle sprain they sent you. Unless you can explain how that affects or helps determine treatment for the sprain.

 

[Shiyuan]

Like I said, I don’t think there is anything wrong with claiming that anything you send an Rx in for is prescription drug management. The difference between naproxen and santyl (as drugs in general) is that the FDA has declared one low risk/safe for people to purchase at Walmart while the other still requires a prescription. Your defense for counting naproxen towards moderate complexity is that the dose you are prescribing is “prescription strength.” Which will all know is a load of crap, but if it gets you paid more, go for it. I just wouldn’t be surprised if there came a day where the feds or a commercial insurer asked for some money back for all of the level 4 visits where you prescribed bacitracin or ibuprofen for your patients.



Correct. And we all know that many times in PP you don’t have access to any of those things to even review. You also have to remember that what you are reviewing needs to be pertinent to the condition you are treating. So the thyroid panel that the PCP ordered and had in the referral note, isn’t something you can review in order to get data points for an ankle sprain they sent you. Unless you can explain how that affects or helps determine treatment for the sprain.

If anything is “prescribed” OTC it’s no higher than a level 3 in my book.

 

[Hybrocure]

Can you bill a level 4 for prescribing antibionics?

 

[HardRoadPaved]

Can you bill a level 4 for prescribing antibionics?

Not in of itself. Still need the other two categories of problem type and data review.

 

[air bud]

Not in of itself. Still need the other two categories of problem type and data review.

Correct. But also...and I repeat think out loud. You have a patient on warfarin and you want to place them on bactrim per the susceptibility report. Well dictate what you just did you in your head. "I reviewed the medication list, patient is currently on warfarin and due to risks associated with potentiation , will instead be placed minocycline.". Well that sounds a lot more like a level 4 than patient prescribed this antibiotic.

 

[Jummy Biffett]

"I reviewed the medication list, patient is currently on warfarin and due to risks associated with potentiation , will instead be placed minocycline.". Well that sounds a lot more like a level 4 than patient prescribed this antibiotic.

This is advanced level Podiometric Medicine

 

[Adam Smasher]

I just wouldn’t be surprised if there came a day where the feds or a commercial insurer asked for some money back for all of the level 4 visits where you prescribed bacitracin or ibuprofen for your patient

I would.

You need to think like an auditor. There's other low hanging fruit for them. They go after me or people I know for shoes, afos, 11042s and the paltry number of skin subs I've placed. Truth doesn't matter to them. It doesn't matter that you obviously placed a graft/dispensed the shoe and have invoices to prove it, they'll tag you for the slightest lack of documentation (failure to document waste, failure to report gait exam, respectively). Someone once did a debridement to subcutaneous tissue and billed 11042, it got denied because he failed to report it as debridement *into* subcutaneous tissue, multilevel appeal, despite that he obviously did the work.

The inverse also applies. You DO include the documentation and your audits proceed uneventfully. To be clear: I don't commit outright fraud, but I have found auditors don't dig terribly deep once you tick off the boxes. They just draft the next chart. I've never had an e/m audit but I know these people want to look for obvious deficiencies, not have ontological discussions about naproxen.

Finally, I don't bill e/m for bacitracin rx, that was a joke.

 

[msuDPM]

I am pretty thorough with my coding and keep a cheat sheet from e/m University at my desk at all times, but I am fairly sparse in my documentation and my notes are typically littered with concise bullet points.

Last I looked, I bill ~50% level 4s. At my new-ish gig I've now been through 2 random internal audits. The audit team agreed with all of my coding except one single chart where they said I undercoded a level 3, which should have been a 4.

It's easier to justify a level 4 than many pods think.

 

[air bud]

I am pretty thorough with my coding and keep a cheat sheet from e/m University at my desk at all times, but I am fairly sparse in my documentation and my notes are typically littered with concise bullet points.

Last I looked, I bill ~50% level 4s. At my new-ish gig I've now been through 2 random internal audits. The audit team agreed with all of my coding except one single chart where they said I undercoded a level 3, which should have been a 4.

It's easier to justify a level 4 than many pods think.

Agree 100%. And I repeat. I repeat literally use the exact words in the AMA chart. Medication management for a chronic unstable condition blah blah blah social determinants of health blah blah blah surgery with associated risk factors blah blah blah

And again a million times easier when you're within a hospital or multi-specialty group that uses epic or something where you can review Labs review notes review x-rays talk to other doctors etc