tci E/M Coding Alert - 2013 Issue 7

Reader Question: OTC Dosage Decisions Don't Automatically Increase MDM

Question: I have a provider who has stated that if he recommends that a patient take OTC meds at prescription strength, such as ibuprofen, this qualifies as moderate for medical decision-making. I am looking for some guidance on this. Is he correct? Florida Subscriber Answer: Moderate decision-making involves other factors besides the risk. In the typically applied payer audit grid, there are three components that determine MDM; the number of diagnostic and management options, the amount and complexity of data, and finally the level of risk. He is correct that recommending prescriptive therapy can be moderate risk. However, at...

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