E/M Coding Alert - 2012 Issue 10
Reader Question: It's the total dosage not the pill size that counts for prescription strength OTC medicines
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Article Overview
This reader Q&A discusses evaluation and management documentation, focusing on how prescription-strength use of OTC medications may factor into medical decision-making analysis. It is aimed at clinicians, coders, and auditors who need general guidance on risk assessment, the components of medical decision making, and how medication dosage relates to documentation review.
Why This Topic Matters
Understanding how medication strength and dosage are considered in documentation review can affect evaluation and management level selection and audit support. The article helps readers evaluate whether medication-related risk is being assessed within the broader framework of medical decision making.
Article Sections
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Question
A reader asks about how provider-recommended use of an over-the-counter medication at prescription strength may influence medical decision-making assessment.
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South Carolina Subscriber Answer
The response discusses the broader components of medical decision making, including risk and other elements used in level selection. It also addresses how medication dosage is viewed in relation to prescription-strength therapy in documentation review.
What You Will Learn
- How medication-related risk fits into medical decision-making analysis
- The broader components used to assess evaluation and management complexity
- Why dosage and documentation details matter in prescription-strength medication discussions
- How audit review may consider therapy recommendations alongside other decision-making elements
Who Should Read This
- Physicians
- Coders
- Clinical documentation specialists
- Auditors
- Revenue cycle professionals
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