# medication management



## tmleavitt (Nov 7, 2007)

I have a question that was raised during a coding audit regarding medication management. On an established patient who is on a prescription medication and is having the prescription refilled (either at the same dose or an increased/decreased dosage) is it considered a moderate or low risk level in medical decision making? There is some confusion regarding this. We always count new rx's as a moderate risk but refills at the office visit are a little gray. Any suggestions would be welcome. Thanks.


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## sbreaker (Nov 12, 2007)

If an established pt is seen and a new med is introduced, all aspects must be considered.  Is the med Ibuprofen?  Is that, really, a moderate risk? Is the med Coumadin?  How does that risk compare to Ibuprofen?  In any case, for a follow up, only 2 of the 3 criteria must be met or exceeded to choose a code (i.e. history, exam, MDM).  If an established pt is there for a refill of the same dose, it seems to me the risk of complications or morbidity is low.  A change in dose, however is different.  But again, what is the med?  I hope this helps.  Isn't this business a blast?


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## DeniseDenise (Nov 12, 2007)

moderate

doesn't matter if they are changing the dose, doesn't matter what the drug is....doesn't matter the illness

of course the rest of the note and medical necessity with dictate the code given.


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## rthames052006 (Nov 12, 2007)

I am with Box of Rain on this one, it doesn't matter what drug it is as long as it is RX management...

Roxanne


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## valleycoder (Nov 25, 2007)

i agree, moderate.


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## werththewait (Dec 31, 2007)

Moderate


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## khaspert (Jan 7, 2008)

Moderate always


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## ashack63 (Apr 16, 2008)

*RX Mgmt*

OTC drugs are low risk, prescription drugs are Moderate and IM or IV parenteral are Hi Risk ( Heperin, Ativan, Thrombolytics, etc)


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## rthames052006 (Apr 17, 2008)

anne1607 said:


> OTC drugs are low risk, prescription drugs are Moderate and IM or IV parenteral are Hi Risk ( Heperin, Ativan, Thrombolytics, etc)



Yes,

I agree that OTC drugs would be low risk also... I hope I didn't give the impression they would be moderate... I guess we do have to be "clear" when we are giving others advice... good catch Anne.

Have a good one...


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## bigredcag (Apr 22, 2008)

just because you are adding/refilling or even changing a script does not mean it is going to be a moderate MDM.  and i agree it doent matter what the script is unless it is OTC medicine.
 MDM you need 2 out of 3 components,
# of presenting problems, amount of data/complexity(diagnostic procederures) and managment option. Just because a script is ordered will not always make a moderate MDM.  this has been a misconception among our doctors too. and being through a medicare audit we got that straightened out in a hurry.


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## ashack63 (Aug 19, 2008)

*MDM vs. Moderate in table of risk*

MDM vs. Moderate in table of risk
you are absolutely correct that an rx does not make MDM moderate complexity. However; in the table of risk (C)on most audit tools, it does carry a moderate risk


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## ARCPC9491 (Aug 20, 2008)

Interestingly enough, on E/M's University case of the week, Dr. Jensen has this same scenario. See below.

CC: Dyslipidemia

INTERVAL HISTORY: The patient is here to discuss risks and benefits of statin medication which was started last time for dyslipidemia with LDL of 160.  Several friends have had adverse reactions to these agents and she wants to know if she really needs to continue this medication.  

PHYSICAL EXAM
NAD, conversant; looks younger than stated age.
BP 124/72  HR 84  RR 18
Lungs: CTA
CV: RRR
EXT: No peripheral edema

Labs: LDL 92

IMPRESSION
1.  Optimally controlled dyslipidemia

PLAN
1.  Continue PRAVASTATIN 10 mg PO QD.
2.  RTC in six months with LFTs and lipid panel.

Time: I spent 16 minutes face-to-face with the patient, over half of which was devoted to counseling and/or coordination of care.  We discussed the role of statin medications in  primary prevention of cardiovascular events.  All questions were answered to her satisfaction. 


For MDM, here is what he did:

Here you get only one problem point for the established and stable problem of dyslipidemia.

Here you get one data point for ordering and/or reviewing labs.

This encounter qualifies as being of low risk based on the presence of one stable chronic illness.


One reader was wondering why the risk was low instead of moderate based on the RX. Dr. Jensen says that in order to qualify for moderate risk for RX management, you should be starting, stopping, or adjusting the medication.

I agree with Dr. Jensen on this. The "risk" is the "risk until the next encounter" if the medication has proven to work and control the issue from the initial encounter to present encounter, if nothing has changed in the patients condition to warrant a change in the med(s), the "moderate risk- RX management" should not be used.


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## HCCCoder (Aug 21, 2008)

Refill of an Rx drug is still considered presciption management. 
So, I would count as Moderate risk. It does not neccesarily mean that the overall MDM would be moderate, but the risk would be for sure.


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## aguelfi (Aug 21, 2008)

I disagree w/ an Rx refill always being moderate.  You don't necessary to have to have an exam to get an Rx refill, you can call in, so why is it worth a moderate risk.  Changing an Rx may require a reaction (positive or negative) to the drug, possible labs or testing, and discussing how to take the meds appropriately and the possible side effects and so-forth.  A refill requires the Dr. to write out an RX.  If there isn't anything wrong, there isn't anything to really manage.  I think this is based on interruption of the rule.  I say Low Risk....unless something changes.


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## beck627 (Aug 22, 2008)

I have been told that if you are prescibing a patient a prescription dose of an OTC (600 mg or greater) then it can be counted as moderate risk. I have also been told that any prescription given can count as moderate risk as well. Interesting points of view on this thread, makes me think about it in a different light. I was thinking that they put into a moderate risk catergory because of the doctor assuming a higher level of risk because that would require many different aspects to be considered before prescribing the med to the patient. Just my thoughts...


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## HCCCoder (Aug 25, 2008)

abenson said:


> I disagree w/ an Rx refill always being moderate.  You don't necessary to have to have an exam to get an Rx refill, you can call in, so why is it worth a moderate risk.  Changing an Rx may require a reaction (positive or negative) to the drug, possible labs or testing, and discussing how to take the meds appropriately and the possible side effects and so-forth.  A refill requires the Dr. to write out an RX.  If there isn't anything wrong, there isn't anything to really manage.  I think this is based on interruption of the rule.  I say Low Risk....unless something changes.



I am NOT talking about exam. I am just talking about the RISK. And, again, like I said before, the RISK is going to be Moderate, not necessarily the level of service. In your case, if the doctor is not going to exam the pt, then the PE would be PF(or none, based on documentation) and # of diagnoses option would be 1 points (if there is 1 est. stable problem) and the risk would be moderate, because it is what it is, it is an Rx drug management. Whether you refill or adjust the medication, it is still counts towards moderate risk. How can you say "if there isn't anything wrong?". Obviously, there is, since pt is on the same medication for long time and is being treated for a chronic condition. This is what I learned from school, meetings, conventions and from my 5 years of experience. 
This is my opinion!
Lilit


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## dmaec (Aug 25, 2008)

morning, I agree with most and with lmartirosyan most of all.
based on the original question - I'd agree - prescription med management fulls under the "MODERATE" Management Options Selected area in the Complication Risk Factor(s) table.  It is what it is....and it's always Moderate.
I won't comment on MDM level because I can see that wasn't your question  You weren't questioning your Number of Dx's or Amount of Complexity, or even your HPI or EXAM components. I'm sure you know how to determine the MDM based on the three.  and your E/M level based on HPI/EXAM/MDM... 
so, back to your original question: 
Prescription medication management, it is what it is and it states it VERY clearly on the Risk Factor Table - it's "MODERATE".
_{that's my opinion on the posted matter}_


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