Prescription Drug Management
Question:
Every patient I see is in pain, and I discuss prescription medications (primarily prescription NSAIDs, Neurontin, and/or muscle relaxers) with almost every patient. If I document “discussed prescription drug management with Mobic, patient defers and will continue Motrin OTC as needed.” Is this prescription drug management?
Answer:
If this is a true clinical management option for this unique patient based on their history, pain level, the number of times you have seen them, imaging, and the patient is not responding to OTC meds, and you determine Mobic is the best next course of treatment for the patient, and they still decline it, this can support prescription drug management. You are still recommending something that has a risk to the patient. This is from the clinical standpoint, which must be clearly documented in the note.
Be aware, many payors have increased scrutiny in this area and may not see it the same way. It can go both ways, so you must be careful. If you routinely do this for every patient to increase your code level and submit all of these as level fours, you may be at risk and set yourself up for an audit from a payor.
Prescription drug management involves a prescription-strength drug that the patient must go to the pharmacy to get. The name, dosage, strength of the drug, and how to take it, along with any rationale for why it is prescribed at the time of the visit, also need to be documented. Payors want to see this documentation in the plan of care. Prescription drug management involves the risk that you take prescribing and the risk to the patient taking the medication.
Refilling a current prescription does not automatically equate to a Moderate level of MDM. The billing practitioner must document the rationale for continuing the medication for the patient at the visit (e.g., the patient’s pain is well-controlled on x mg at this time, and he/she will continue the current dose).
*This response is based on the best information available as of 1/16/25.
