Pulmonology Coding Alert

Question: I have a report from a recent evaluation and management (E/M) visit with an established patient. The pulmonologist advised the patient to continue taking their current medication at the same dose, and the provider renewed the prescription.

Does this count toward medical decision making (MDM)?

Arkansas Subscriber

Answer: The CPT^® E/M code set guidelines include a Levels of MDM table to assist you in determining the correct level of MDM for an E/M visit. Prescription drug management is listed as an example in the Risk of Complications and/or Morbidity or Mortality of Patient Management column at the Moderate MDM level. Unfortunately, the 2024 CPT^® code set doesn’t specify what prescription drug management consists of; the same currently holds true for the 2025 CPT^® code set.

However, you can enlist the assistance of your Medicare Administrative Contractor (MAC) to clarify any confusion. For example, Novitas Solutions, a Part A/B MAC, 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,” in its E/M frequently asked questions (FAQs). The MAC also adds that prescribing a new drug, adjusting the dose of an existing prescription, and refilling a medication count as prescription drug management.

The examples Novitas Solutions present match the encounter you describe, but two guidelines the MAC offers may help. The payer instructs that the provider needs to document the drug, dosage, and the management, but the documentation cannot simply list “medications.” The required documentation indicates you can assign a moderate level of risk to the E/M visit as long as the physician goes beyond listing the patient’s medication and notes the management decision associated with the drug, even if the physician is continuing the same drug and dose.   

Identifying the amount prescribed along with a note that shows the pulmonologist has decided not to change either of these things at this encounter counts as moderate risk for complications/morbidity/mortality involving the patient’s continued use of prescription drugs.

Important: Novitas mentions that “if medications are just listed in patient’s medical record, credit is given for past history.” This means that if a “medication list” is included in the progress note without specifying the corresponding management options involving any of the medications that appear in the list, the provider cannot get credit for prescription drug management when determining the MDM level.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC