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Wiki Continue medication - MDM level?

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MedicalCoder432

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Many times my providers list problems they addressed during an encounter, and simply write, "continue (specific medication)."

I don't think this amounts to prescription management, but what do you think? And if it does not amount to "level 4" prescription management, is it simply a lower level? Maybe level 3, because they have to make a decision for the patient to continue their medication or not, but they are not doing a refill, medication change, or listing the specifics of the dosage?
 
It needs to be clear that the provider performed medical decision making about the prescription. Below are some references to review:

NGS: Please define prescription drug management relative to MDM. Answer: In order to count prescription drug management there must be documentation of at least one of the following factors: A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered. Documentation of a decision to initiate a new prescription drug(s). Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

FAQs: Evaluation And Management Services (Part B)

www.novitas-solutions.com
https://med.noridianmedicare.com/web/jfb/specialties/em/em-top-provider-q-and-a Q7
 
csperoni said:
It needs to be clear that the provider performed medical decision making about the prescription. Below are some references to review:

NGS: Please define prescription drug management relative to MDM. Answer: In order to count prescription drug management there must be documentation of at least one of the following factors: A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered. Documentation of a decision to initiate a new prescription drug(s). Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

FAQs: Evaluation And Management Services (Part B)

www.novitas-solutions.com
https://med.noridianmedicare.com/web/jfb/specialties/em/em-top-provider-q-and-a Q7
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Thank you. So if my provider simply wrote "continue medication," this does not show decision making took place regarding the medication. Does that mean that this column of MDM should be leveled at a 2?
 
I would call this an example of poor documentation and use it as a learning tool for moving forward. If the records don't show decision making, you cannot consider it as OTC management either. If there were other items to level risk for higher than 2, you could just ignore the "continue medication" statement. If no other items, and no data, I would have to default to overall straightforward for level 2.
 
I pose this question because I have been told different things by different auditors. If the list of all medications with strength & dose etc. are in the note (such as * Metoprolol Succinate ER 50mg oral tablet extended release 24 hour 1 tablet once a day, 90 days 3refills *Furosemide 40mg oral tablet take 1 tablet once daily, 90 days, 3refills) AND the provider states I have reviewed patient medications AND in the assessment a statement like Benign essential hypertension I recommend he/she continue metoprolol and furosemide . . . would you allow medication management? ( in the HPI it might say something like hypertension has been stable)
 
Gator said:
I pose this question because I have been told different things by different auditors. If the list of all medications with strength & dose etc. are in the note (such as * Metoprolol Succinate ER 50mg oral tablet extended release 24 hour 1 tablet once a day, 90 days 3refills *Furosemide 40mg oral tablet take 1 tablet once daily, 90 days, 3refills) AND the provider states I have reviewed patient medications AND in the assessment a statement like Benign essential hypertension I recommend he/she continue metoprolol and furosemide . . . would you allow medication management? ( in the HPI it might say something like hypertension has been stable)
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I would count that if they were the prescriber.

If it was just a list, there was nothing else stated, and you couldn't tell who was prescribing (managing) I would not.
Even if it stated, "cont. meds." or something like that.

It is medication management.

Christine's post helps explain this.
 
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