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Risk Level for RX

Jamie Posted Tue 17th of January, 2017 14:50:51 PM
If a provider recommends an RX, but no RX is written at time of service, is the risk considered low or minimal?
SuperCoder Answered Wed 18th of January, 2017 01:51:23 AM

When there is no documentation of the prescription, then it cannot be counted for the level of risk. Only recommendation is not enough, it should be documented. If it is not written at the time of service, and provider recommends something, so add that recommendation to the service documents as ADDENDUM, then you can count that as workup for risk level. Addendum can be added even after the service, only if provider recommended at the time of service, but somehow that was not documented. Then select the risk level according to the prescription or service provided.

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