Prescription Drug Management

Question: My coder tells me that when I use a prescription medication on a new problem that I automatically qualify for moderate level decision making. I'm a pediatrician, and for me this fits a lot of what I feel are lower level problems. Am I under-coding my services if I bill 99213 with some prescriptive management?

Answer: Not necessarily. Your coder is referencing the decision-making tables that Medicare and other payers may use to determine the level of medical decision making. Technically he or she is correct, but that may not save you in a medical necessity review. Your instinct seems to me to be much more in tune with medical necessity.

One of the three tables gives points for the number of problems dealt with: one point for each established stable problem, two points for a worsening established problem, and three points for a new problem. We talked about these in the last issue. There is no issue with a new problem getting you three points, or moderate complexity, in this table.

The sticky point is the part about writing for a prescription medication. Your coder is correct that the entry "prescription drug management" is listed in the "moderate" section. But using this to determine the level of risk is interpreting the table somewhat mechanically, seemingly without a good grasp of medical necessity.

The mere presence of prescription drugs does not necessarily qualify for moderate complexity. CMS has indicated that writing a prescription for a seven- or 10-day supply of an antibiotic is not considered to be a moderate level of complexity. At least one Blue Cross company has indicated that prescription drug management involves more than the use of prescription drugs. It may mean a change in regimen, the addition of an agent, or the worsening of a problem. In other words, any prescription is not a guarantee that a payer will see this your way.

Consider the entry in the first column of the table, Presenting Problem, under low level decision making. It says "acute uncomplicated illness or injury; e.g., cystitis, allergic rhinitis, simple sprain." Does the new problem that you were describing fit into this category? If so, you might be more accurate - as you indicated - with the low level decision making associated with a 99213.

I'm not trying to diminish your work in any way. I am only saying that a medical necessity review may find the problem more of a low level one, despite the fact that a prescription was written. Remember that those tables were in use as far back as 1990 - almost 20 years ago. The ink may not have changed on the page, but the interpretation may have moved away from the literal.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the January 2010 issue of Physicians Practice.