# Table of Risk - I am looking for any articles



## jmcyr9 (Mar 8, 2010)

I am looking for any articles or documention regarding the specifics for the table of risk, prescription drug management. It seems that there is a difference of opinion regarding what is considered "Prescription Drug Management". Some say if you write any script that it counts and others feel that you have to actually be managing a script for an illness. Looking for what other have found or interpret it.


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## LindaEV (Mar 8, 2010)

I don't have an article to site, but have read many times that simply _"refilling"_ an rx for a _stable_ disease shouldn't count, where as a new rx would. I tend to follow this. (remember you can meet the moderate risk with only having two or more stable chronic dz anyway)
Unfortunately the documentation guidelines don't specify, so unless a carrier has specific instructions pertaining to this, its pretty much left open to interpretation.


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## Juanita L Deal (Mar 8, 2010)

I have been told that if you can get the medication over the counter, ie: without a script, even if the doctor writes one, then it doesn't count.  Also, the last poster said something about not counting refilling a prescription for a stable condition, however it has been argured to me that refilling a prescription still carries an inherent risk because you have to judge if anything has changed that would make the medication act differently.


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## dballard2004 (Mar 8, 2010)

If a patient comes in for a refill of a medication for one chronic problem, I would assign this as low risk.  If you reference the presenting problem(s) on the table of risk, one stable chronic illness equates to a low risk.  If the patient presented for multiple refills, again referencing the presenting problem(s) on the table of risk, this would equate to moderate risk because of two or more stable chronic illnesses.  Again the risk is only one part of the overall MDM.

Just my two cents for whatever it is worth.


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## FTessaBartels (Mar 8, 2010)

*Table of Risk*

The table of risk is an attempt to quantify the risk TO THE PATIENT of the presenting problem(s) and/or recommended treatment.  

Prescription drugs pose the same risk to the patient whether it is a new prescription for a new problem or a refill of an existing medication for a chronic problem. (Although I DO agree with Juanita - if you are giving the patient a Rx of a readily available OTC drug, I'd be inclined to NOT count this as moderate risk.)

Whichever box on the table of risk has the "highest" level of risk is the risk for that encounter. 

So even if you have only one stable chronic illness (e.g. diabetes), if you are getting a refill of your Rx for insulin you have moderate risk. 

Now, whether that will translate to moderate MDM will depend on whether you have at least 3 problem points or 3 data points, in addition to moderate risk. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## dballard2004 (Mar 9, 2010)

I resepectfully disagree.  Refill of a medication for one stable chronic illness is low risk not moderate.  Again reference the presenting problem.


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## vpcats (Mar 9, 2010)

FTessaBartels said:


> The table of risk is an attempt to quantify the risk TO THE PATIENT of the presenting problem(s) and/or recommended treatment.
> 
> Prescription drugs pose the same risk to the patient whether it is a new prescription for a new problem or a refill of an existing medication for a chronic problem. (Although I DO agree with Juanita - if you are giving the patient a Rx of a readily available OTC drug, I'd be inclined to NOT count this as moderate risk.)
> 
> ...



Agree.  Even "CPM" (Continue Present Meds) carries a risk and is "moderate" (assuming these are prescription meds).


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## jwestfall (Mar 9, 2010)

I also agree.  The patient is still at risk with any prescription medication regardless if it's new for the patient or not.  I always code to Moderate risk even if the just continue a current medication.


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## dballard2004 (Mar 9, 2010)

Prescription drug management has always been defined to me as either starting, stopping, or changing the patient's meds.  If the patient presents for a refill of a med for a stable problem, you are not starting, stopping, or changing the meds.  You are just refilling it.  You already know how they are going to respond to the meds; otherwise you would not be refilling it!  A stable chronic problem would net low risk.  Reference the Table of Risk and look at the Presenting Problem.

If you were refilling multiple meds, then I agree this would be moderate risk.


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## akwort (Mar 11, 2010)

The Risk table is the most difficult piece of the Medical Decision Making section to understand. The column " Management Options Selected" has examples of "management markers" for each level of risk which correlate with the same levels of risk in the other two columns. For management of a chronic stable medical problem with prescription drug(s) the choice of moderate is not based on the idea that drugs are dangerous or risky but rather that the idea that a chronic problem that requires a prescription drug for management is an inherent increased medical risk for the patient.
The same is true for the surgical risks in the same column. The risk level is not attained primarily because the patient may die from the surgery but rather that the primary condition requiring the surgery is the risk driver.
I am sorry if I sound pedantic. I practiced for 16 years and have spent 6 years educating myself and other practitioners about E&M Coding. It is a tough area and I still learn.
AKW MD CPC


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## dballard2004 (Mar 11, 2010)

I respectfully disagree!  Management of one prescription in no way moderate risk, but low risk because it is one stable chronic problem based on the nature of the presenting problem.

This is my last post on this subject. I have stated my opinion here and quite frankly, I'm tired of defending it!


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## SCanterbury (Mar 11, 2010)

"Managing" a patient's prescription drugs is not limited only to the visits at which the prescription is started, stopped, or changed, but would apply to all visits involving decision-making as regards to the drug, even if the decision is to keep everything the same.

For example, it may be the 3rd follow-up visit after a doctor has presribed a drug, and it is time to re-evaluate whether or not the drug should continue to be taken as it is at present, or whether 


the dosage should be changed
some other drug should be used instead
some other management option besides an rx drug should be explored, like a surgical option

In the end, it may be decided to hold off on any changes for now, and for the patient to continue with the current drug. Even though no changes were made, this visit involved prescription drug "management."

This is the view reflected in this AAFP article:

http://www.aafp.org/fpm/20001100/coding.html

_Defining risk 
Q: The table of risk in Medicare's "Documentation Guidelines for Evaluation and Management (E/M) Services," lists "prescription drug management" in the moderate risk category. I believe this term would cover making a change in a prescribed medicine, but does it also cover making a decision to continue a patient's prescription drug regimen? Likewise, "drug therapy requiring intensive monitoring for toxicity" is listed in the high risk category. I believe this would include checking an INR for a patient on Coumadin, but what other medications and tests might be applicable?

A: Neither the table of risk nor any other part of the documentation guidelines define what "prescription drug management" or "drug therapy requiring intensive monitoring for toxicity" mean. A decision to continue a particular medication might be considered "prescription drug management" since you would be managing the patient's prescription medicine and since a decision to continue a patient's current medication may involve as much risk as a decision to initiate a prescription drug regimen. But whether this example or the second one you gave would fit the descriptions of risk given in the table would be a matter of judgment for both you and any reviewer. _

Here's an example of a Medicare contractor (NHIC) agreeing:

http://www.medicarenhic.com/ne_prov/seminars/FairSpring2009QandA.pdf

_Question 8. What exactly is meant by prescription drug management in the table of risk? Do I have to add, stop or adjust a drug?
Answer 8. Prescription drug management in the risk table is very easily defined and described. It can be a simple monitoring or a prescription drug (any single drug), assessing the need for the continued use in the plan of care and assessing the need for a change in drug, dose or discontinuing it altogether. There does not need to be a change of any kind and long as the medical record reflects the fact that a prescription drug was considered for the plan of care of a patient. A list of medications alone would not satisfy the medical record reflecting that a prescription drug was assessed for use in the plan of care for that particular date of service. The record should state something like: "continue XYZ at the same dose for (diagnosis)". _

First Coast Service Options, Medicare contractor for FL, in their online training module, seems to be a bit more lenient when they say that a provider should document current medications pertaining to the problems the patient is being seen for to receive credit rx drug management. There is no mention of any changes needing to be made in order to receive the credit.

Even though the E/M Guidelines don't expound upon what is meant by prescription drug management, we do get insight into this concept by referring to the "pharmacological management" 90862 CPT code provided for psych MDs to bill when the patient's psychotherapy is being handled by another provider (like a psychologist) who cannot prescribe or manage medications. Of course, "pharmacologic management" and "prescription drug management" are the same concept.

The Summer 92 CPT Assistant says that with pharmacologic management...

_...The physician is evaluating how the medication is affecting the patient, determining the proper dosage level and prescribing medication for the patient for the period of time before the patient is next seen._

After evaluating the medication's current effects, the physician may conclude that the dosage is just where it should be and so no changes are made. Credit is given for the decision-making process that happens when a patient is being evaluated for a condition for which they are also currently taking meds for, even if that process results in no changes.

CMS has also created a "lower level" pharmacologic management code for use by psych providers: M0064. Note that the OIG referred to both of these codes as being "medication management" codes:

http://oig.hhs.gov/oei/reports/oei-09-04-00220.pdf

_Medication management may be billed under one of two CPT codes: 90862 (psychiatric pharmacologic management) or M0064 (brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic, and personality disorders)._

Now see above where code M0064, which is descrbed as a drug "management" code, can involve *monitoring* or changing drug prescriptions, not just changing (or starting/stopping).

So even though "management" of a prescription drug isn't explained well in the E/M Guidelines, both CPT and CMS have elsewhere made it pretty clear that evaluating the effectiveness/monitoring current meds qualifies as "managing" a patient's meds.

Seth Canterbury, CPC, ACS-EM
Healthcare Consultant
tscanter26@hotmail.com


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## aguelfi (Mar 12, 2010)

I asked my local carrier FCSO (FL) about this and this is the repsonse I received from the auditors.

_Q.What exactly is meant by prescription drug management in the table of risk?  Do I have to add, stop or adjust a drug? __

A. 7. For prescription drug management to have taken place, the documentation must clearly demonstrate that the physician reviewed the patient's drugs and decided to keep them as they are or to change them.  Simply listing the patient's drugs is not sufficient._

I defer to my local carrier since they have the overall say for me.  As stated in the post above, carriers differ with their rules and we are to abide to our local carrier rules.  It doesn't do me any good to argue a point that was issued by Trailblazer when I have First Coast.  For me, I follow this rule, if you review the meds and decide to keep it the same, it's Moderate risk.  If you still aren't sure or you don't agree, do what I did and contact your carrier.  They will issue you a response.


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## 1071471 (Mar 17, 2010)

I would consider refilling medications as RX drug management whether the problem is stable or not and if there is a single RX or multiple RX. To me, it's manging the overall patient risk by RX managememt.


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## scorrado (Mar 18, 2010)

I am certainly no expert in this but to state that "you already know how someone is going to react to a certian medication" is being very short sighted.  You can be prescribed a certain medication numerous times and have no issues and then suddenly have a reaction.  I do agree refilling a RX is moderate risk for this very reason. Just my opinion.


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## dballard2004 (Mar 18, 2010)

I am in no way being short sighted.  I am simply stating my opinion of this scenario.  The purpose of these forums if for all of us to be able to express our opinions and share our expertise with each other.  Many times while reviewing these forums, I often find that if someone disagrees with one's post, instead of just stating they disagree, they want to belittle the other person (don't believe me? check out some of these forums and you will see what I mean).  As we all know, there are some absolutes in the coding world and some parts that are subjective (E/M being one), but we all have something to bring to the table.  If you disagree with me on this scenario that is all well and good, but you don't have to be rude to me by calling me short sided.  

Once again, I am only stating my opinion.


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## RebeccaWoodward* (Mar 18, 2010)

*TEAM* = Together Everyone Achieves More


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## scorrado (Mar 18, 2010)

I did not mean to be rude and if you took it that way I apologize.  I was just trying to point out that we have to look at all angles and the "big picture".  Taking a medication before does not mean that you cannot have a reaction to it at a later time. Sorry if it came out wrong.  Have a great day!


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## coderforlife (Apr 29, 2010)

*prescription drug management*

I am wondering if a patients current medications are listed under a section of the document titled "current medications" and you may have as few a one and as many as 20, and when we get down to the mdm section aka the assessment and plan and all the doc says is "continue current medications", would this be something we could give him credit towards prescription drug management? I read somewhere recently and now I can't find it, that the doc needs to state he reviewed current medications that the patient is taking, and state which medication that is and that he would want the patient to continue its use. Just listing the med's, I believe does not allow us to give credit for drug management. I think the med's need to be stated so we can identify if it pertains to the current condition. Any advice as to a link I can turn to for a hard copy to support my thinking.


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