Pediatric Coding Alert

Question: Can you count a routine prescription refill as a moderate level of risk when determining the level of medical decision making (MDM)?

Arizona Subscriber

Answer: If you consult a chart to determine level of risk, such as the one CMS provides at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf), you will see that “prescription drug management” is listed as a clinical example of a moderate level of risk in terms of management options for a given presenting problem.

However, in order to use it as a factor, you need to know what constitutes management, which is a question you should ask each of your payers. Most will follow a similar policy to the one outlined by Novitas Solutions, a Medicare Administrative Contractor (MAC), which states:

“Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.
“If medications are just listed in patient’s medical record, credit is given for past history.”
(Source: www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056).

In this particular policy, new prescriptions, changed prescriptions, and even refilled prescriptions count as a moderate-level risk management option. However, the key part of Novitas’s policy is stated in the last sentence. Simply put, according to this policy, you cannot just list the medication and dosage in order for a prescription refill to count as a management option.

To count a prescription refill as a moderate-level management option, you will need to document the reason your provider has decided to continue prescribing the current medication and/or maintain the current dosage level of that medication. So, providing your payer follows a similar policy, refill documentation that is accompanied by a statement that your provider has made some kind of medication assessment will enable a prescription refill to count as a moderate level of risk.