Primary Care Coding Alert

Reader Question:

Medication Evaluation

Question: Under which key component should we count physician review of a patients medication list during an E/M visit?

Utah Subscriber

Answer: This activity counts as one element of the past history review. According to CPT, past history includes the patients past experiences with illnesses, operations, injuries and treatments.

You Be the Coder and Reader Questions were reviewed by Judy Richardson, RN, MSA, CCS-P, senior consultant at Hill & Associates, a coding and compliance consulting firm based in Wilmington, N.C.; Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; and Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians.

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