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Prescription Drug Management: Is it a Level 3 or a Level 4?

June 29th, 2017 - J. Paul Spencer, CPC, COC
Categories:   Audits/Auditing   Drugs|Pharmaceuticals|FDA  
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If you place four auditors around a table and place a typical established patient visit in front of them, what tends to follow is a scene that resembles less about building consensus and more along the lines of a National Geographic special regarding the hunting habits of hyenas. Perhaps no one area is more contentious and liable to lead to such a scene as a simple three-word phrase from the Table of Risk: "Prescription Drug Management."

In the early days on the E&M Guidelines, many physicians interpreted this small, unassuming phrase as an invitation to increase the complexity of simply visits based on the prescribing of any medication. With every new generation of auditors coming on to the scene, this myth seems to reappear and propagate anew.

First, a definition of these three words, as it applies to the E&M Guidelines, needs to be found and understood. In general, prescription drug management can be any one of the following:

The duration of the prescription drug regimen is not taken into account when applying these factors to the Table of Risk. The problem with jumping forward with moderate complexity Medical Decision Making (MDM) simply on the strength of the prescription drug management becomes a question of acuity. The Table of Risk is but one of three factors that determines the level of MDM. In many cases, the category of problem necessitating the visit will be the determining factor for MDM. As an auditor, it usually comes down to a decision regarding whether a presenting problem is self-limiting/minor or a new problem to the examining physician with no workup planned. A patient can present with two minor problems and the MDM still falls under low complexity.

The auditor must walk a fine line between making a sound auditing determination and leaving it up to the physician to paint a clear picture of the acuity of the patient. There are going to be times where the presenting problem reaches the acuity of a 99214, but the documentation doesn't support it. Conversely, there will be other times when the presenting problem appears to be minor, but the physician's documentation points to a more complicated condition.

In the end, if the documentation is not pointing to one, clear final answer, consult the physician. While it is tempting to defer to a higher level based on the fact that physicians go through ten years of intense scientific training to become doctors, different physicians will have different comfort levels when measuring patient acuity. Prescription Drug Management may look like a surefire level 4 on paper, but in questionable cases, the physician is the best judge of acuity.

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