Wiki E/M Risk Help Please :-)

[lisafer360]

Office visit for established patient - 2 acute sprains due to MVA, one of neck and one back. Doc orders massage therapy, ice and script for naproxen 500mg and methocarbamol 500 MG.

Is this low risk because of the level of acuity of sprain and the massage therapy/ice...or does the level bump up because of script for naproxen and methocarbamol?

Thank you in advance!

 

[meghanhannus]

Hello lisafer360,

This would be low risk as the Presenting Problem is sprain and the Management Option is therapy. The script would not bump it to moderate as the moderate Management Option is for prescriptive drug management which is for example the patient has HTN and a HTN med is increased/decreased etc....

Hope this helps~

M.Hannus, CPC, CPMA, CRC

 

[lisafer360]

Thank you!

 

[kmartinez]

Hello lisafer360,

This would be low risk as the Presenting Problem is sprain and the Management Option is therapy. The script would not bump it to moderate as the moderate Management Option is for prescriptive drug management which is for example the patient has HTN and a HTN med is increased/decreased etc....

Hope this helps~

M.Hannus, CPC, CPMA, CRC

Hi M. Hannus, I am curious how come the script for methocarbamol does not classify as prescription drug management. We would bump it up to a moderate level because the doctor is prescribing the drug=prescription drug management. No where does it say that it is only for illnesses such as HTN etc. Unless I missed that somewhere...if so I'd love to get some documentation on that to present to my boss so we can provide our providers with accurate information and education.

KM CPC

 

[lisafer360]

M Hannus - I have found multiple conflicting information on this issue. The most "official" information I can find is as follows from a Q&Q from Medicare FCSO:


Q. During an evaluation and management visit, what constitutes “prescription drug management?”
A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”

Do you have any opinions on this.....(I am just being conversational....not saying you are right or wrong....)

 

[lisafer360]

Hi M. Hannus, I am curious how come the script for methocarbamol does not classify as prescription drug management. We would bump it up to a moderate level because the doctor is prescribing the drug=prescription drug management. No where does it say that it is only for illnesses such as HTN etc. Unless I missed that somewhere...if so I'd love to get some documentation on that to present to my boss so we can provide our providers with accurate information and education.

KM CPC

I agree - I think the based on what I found from Medicare FCSO and other sources that it seems very reasonable to have the risk be moderate if you are either adding/changing a medication based on that days visit.

 

[meghanhannus]

M Hannus - I have found multiple conflicting information on this issue. The most "official" information I can find is as follows from a Q&Q from Medicare FCSO:


Q. During an evaluation and management visit, what constitutes “prescription drug management?”
A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”

Do you have any opinions on this.....(I am just being conversational....not saying you are right or wrong....)

Honestly, this is a grey area when it comes to auditing/coding the Risk of Complication and/or Mortality element within the MDM. Where I audit we take into consideration the nature of the presenting problem as the overarching criteria; in your example given the presenting problem was acute sprain (low risk). The management options of massage therapy,ice, NSAID (which can be bought otc) and muscle relaxer would have also been a low risk. An example of another low risk is the presenting problem of ear infection and the provider prescribes an antibiotic. We would not chose moderate risk simply for the new prescription of antibiotic as the presenting problem is an acute uncomplicated illness . An example of moderate risk would be a patient with DMII, HTN, HLD and the provider is decreasing the dose of Metformin and changing the patient's HTN medication. Since the nature of the presenting problem (s) is one or more chronic illness and there was prescription drug management this would fall under moderate. Again, this is how we level out risk where I audit and it seems as if different places have their own guidelines to follow. Unfortunately, there is no regulation from CMS on prescription drug management but I would suggest contacting your local MAC.

 

[zoinks071]

I would also agree that the prescription management would rise to the level of moderate risk. This is taken from our the E&M FAQ from our local MAC NGS...

"Please explain NGS’s interpretation of medication prescription management as it relates to MDM. Does renewal of a prescription for long-term medication(s) differ from a prescription for a new medication?

Answer: NGS refers to the CMS E&M guidelines in assigning moderate risk to prescription drug management. The guidelines do not differentiate between newly ordered and renewed medications, nor do they classify any particular prescription medication as being more or less risk-associated than others. Since risk is one element in assessing the complexity of medical decision making (the others being the scope/duration of conditions and the scope of diagnostics and medical records), all factors are included by reviewers in calculating the complexity of MDM. Updated 6/9/2017"

I agree that the overall presenting problem may be low severity, but the highest level of risk in any one category of presenting problem, diagnostic procedure or management options determines the overall risk according to CMS' Marshfield audit tool.
I hope this helps.