While this likely depends on the payer's rules, I count it under risk in MDM calculation is there is some documentation of "management," even if no changes are made. Documentation of reviewing the dosage, discussion of side effects, etc. is management and the decision to continue as is, is still MDM. Many payers agree. Here's a snippet from Novitas as an example (
https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056):
"When can prescription drug management be credited in the medical decision-making risk of complications chart?
Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.
If medications are just listed in patient’s medical record, credit is given for past history."
Hope that helps!
Leesa A. Israel, BA, CPC, CUC, CEMC, CPPM, CMBS, AAPC MACRA Proficient
Head of Publishing, Editorial & Technology
AAPC