Wiki Medication management

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hanihosni

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For an inpatient follow-up E/M visit, If the provider documents current medication review, stating that the medication list in the medical record is true, accurate and complete to the best of her knowledge, can that be considered prescription drug management when determining the MDM level for the visit ?
 
hanihosni said:
For an inpatient follow-up E/M visit, If the provider documents current medication review, stating that the medication list in the medical record is true, accurate and complete to the best of her knowledge, can that be considered prescription drug management when determining the MDM level for the visit ?
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I am no longer keeping up with all of the changes going on in E&M coding these days, but based on how I was trained over the years, I certainly would not that consider that medication management - there's no documentation of anything being 'managed' here if the only thing the provider is doing is looking at the list and saying it's accurate. 'Management', to me, means that the provider is actively involved in making decisions about whether or not the prescriptions and dosages that the patient is taking are clinically appropriate for the conditions and severity of problems that the patient is experiencing. Just verifying the accuracy of a list doesn’t involve any medical decision making. Perhaps other coders here who are more current on the guidelines can add to this.
 
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Thomas is correct. Listing the medications does not count. The provider needs to prescribe, discontinue, change, or instruct to continue/renew. There should be a DECISION. Confirming which medications that patient takes is not a medical decision.

There have been several other discussions including links to references:

PS - It may count as medication reconciliation post discharge if you bill for that. I think some MA plans even pay for it. The practices I work for do not use 1111F, so I can't give any further advice than the HCPCS code exists.
 
If the provider lists all the medication a patient is taking with the name dosage etc & states medications are reviewed and then in the assessment or plan says something like Diabetes & HTN continue current medication . Can that be counted as medication management? I'm questioning because while he does list specifics of meds and reviews them does not state specifically in the plan which medication should be continued for DM or HTN etc.
 
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