Pediatric Coding Alert

Question: Our pediatrician told a patient to continue taking a given medication at the same dose. She did not prescribe any refills. Can this be counted toward medical decision making (MDM)?

Kansas Subscriber

Answer: Prescription drug management is listed as an example of a moderate-level risk of morbidity from additional diagnostic testing or treatment under the risk of complications and/or morbidity or mortality of patient management element of MDM, but CPT^® currently has no guidelines to help you determine exactly what prescription drug management consists of.

However, you can look to Medicare for some clarity, especially in your specific circumstances. According to Novitas Solutions, the Part A/B Medicare administrative contractor (MAC), “credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service.” Novitas goes on to provide several examples, such as prescribing a new drug or changing the dose or frequency of an existing drug.

This is referred to as ongoing prescription drug management, and medication refills or a simple instruction to the patient to continue medications would not qualify as prescription drug management.

While these examples do not exactly reflect the encounter you describe, Novitas then goes on to offer two guidelines that can be applied. They tell you to document the drug, the drug dosage, and the management, but not to simply document medications alone. This indicates you can assign a moderate level of risk to your encounter providing you go beyond listing the patient’s medication and note the drug and the amount prescribed along with a note that shows your pediatrician has decided not the change either of these things at this encounter.

Coding alert: Novitas also states that “if medications are just listed in [a] patient’s medical record, credit is given for past history.” This means that, under the new office/outpatient evaluation and management (E/M) guidelines, which no longer use history in calculating office/outpatient E/M levels, you will not be able to simply state medications in the documentation and use that to determine the level of an office/outpatient E/M. Simply put, without notation about the medication, dosage, and the provider’s decision to either change them or maintain them, you cannot get MDM credit.