Wiki Counting checking PDMP (Prwescription Drug Monitoring Program) as Complexity of Data

[rhotonscott]

Email sent to Our Medical Director:
I noticed that ‘and/or checked PDMP’ was added to <Reviewed old records…> check box for Complexity of Data for coding points.
If this is being done as part of Agency protocol, it does not count for coding purposes and should not be included as it may result in up-coding. There is no complexity in decision-making to just follow a protocol.
Unsure how this got changed as this was not the way it was set up per my prior recommendation, and my professional opinion is: this verbiage should be removed and another check box added: <PDMP checked per Agency protocol> that does not link to coding.
I have no problem educating prescribers to check <Reviewed old Records> when they check the PDMP on established patients, not on controlled meds (ie not part of protocol) and document why: “checked PDMP as client has history of Benzo abuse” or “ checked PDMP as client has a SUD Dx” or “client has been using up recent prescriptions prior to renewal date; checking PDMP for possible prescription abuse”. This does show additional ‘work’ on the part of prescribers which may allow for higher coding level.

Experienced E/M coders-please provide input as the Director disagrees with my stance

 

[thomas7331]

I am curious about your statement that there 'is no complexity in decision-making to just follow a protocol' and I think the issue may hinge on that - is this information from a source such as a local payer guidelines that you follow, or did a provider share this? I have read a lot of different guidelines on E&M and MDM, but haven't ever come across anything that states this. My own clinical experience is limited, and I'm not experienced in the area of drug monitoring, but I'm not sure I would agree with that. Some medical protocols can be quite complex and following a protocol could indeed contribute to the level of MDM required for a patient. My first thought is that this would be a decision to be made with the input of the providers who are knowledgeable about how the protocol affects the complexity of their work, but I would like to understand better how you arrived at this conclusion.

 

[rhotonscott]

checking PDMP as part of agency protocol

I like TrailBlazer's (old MAC from Colorado replaced by Novitas in Nov 2012) explanation for Order and/or review old records from their audit sheet:
"Practice or protocol-driven record ordering does not require physician work thus should not be considered when coding E/M services."
My professional opinion is: if they check this box it should reflect some thought process and not a following a required guideline. Documentation should reflect a medical necessity for obtaining the additional info, other than as Agency Protocol : history of SUDs, prior prescription abuse, or scripts running out too soon, etc). However, if when doing this as part of protocol, they document an issue and follow-up, then it meets criteria for data complexity for the follow up.
I do like your thoughtful perspective Thomas 7331 regarding querying physicians for input