OVER THE COUNTER VS. PRESCRIPTION DRUGS

A drug is a substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease. Over the counter (OTC) medications allow self-treatment of conditions such as allergies, headaches, and joint pain— Hence the name.

These medications may be purchased off the shelves in drug stores. Other drugs, prescription medications, require authorization from a healthcare provider and must be bought at a pharmacy. These drugs are regulated by the Federal Drug Administration (FDA).

Sounds simple, one just needs to review the record for documentation of a prescription, however, did you know that health plans completely cover certain OTC products when patients present a prescription?

Under Affordable Care Act requirements, insurers must cover certain OTC preventive medications at 100% with no co-pays, co-insurance, or deductibles, but only when the patient obtains a prescription. In addition, health care reform rules (effective January 1, 2011), allow distributions from health flexible spending arrangements (FSA) and health reimbursement arrangements (HRA) to reimburse the cost of OTC medicines or drugs when they are purchased with a prescription.

When leveling an E/M service, OTC medication supports a low-level risk while prescription drug management warrants a moderate level of risk. As mentioned, a coder cannot assume a moderate level of risk just because a prescription was written. It is important to take a deeper look into the medications to determine if this is classified as an OTC medication or prescription medication.

Remember that prescription drug management is based on documented evidence that the provider has evaluated the patient’s medications as part of a service. This may be a written and/or discontinued prescription, or a decision to maintain a current medication or dosage. Simply listing current medications is not considered “Prescription drug management.”

EXAMPLE #1:

• Scenario: 58-year-old female with sore throat, fever, and swollen lymph nodes in the neck. Rapid strep positive results. Prescription given for Amoxicillin 50 mg once daily for 10 days.
  • Documentation supports prescription drug management as Amoxicillin is a prescription only medication. Therefore, a moderate risk level is supported.

EXAMPLE #2:

• Scenario: 21-year-old male presents with nausea and vomiting since eating Mexican food earlier that evening. Prescription given for Omeprazole 10 mg once daily.
  • Omeprazole is a medication that is available over the counter. Therefore, a low risk level is supported.

Excite Health Partners an ECLAT Health Solutions Company

Sources:

https://medicare.fcso.com/FAQs/Answers/0324049.asp

AMA CPT 2023 Professional Edition