tci E/M Coding Alert - 2022 Issue Q3

Reader Questions: Understand When Rx Management Affects MDM

Question: Our pediatrician gave a patient a trial/sample medication. The doctor documented instructions and medical necessity in the patient’s record. Does this qualify as moderate risk for prescription drug management? AAPC Forum Participant Answer: The fact that the pediatrician gave the medication to the patient as a sample instead of as a prescription does not alter the medical decision making (MDM) risk level, providing the pediatrician monitors the medication’s effectiveness in treating the patient’s problem. The moderate risk of morbidity from treatment MDM level is for prescription drug management (emphasis added). Additionally, risk is determined not...

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