dmdahlgren
New
I am a new coder and I have some charts where the physician states medication reconciliation was performed. Does this count as the physician ordering a prescription for the E&M calculator?
I am a new coder and I have some charts where the physician states medication reconciliation was performed. Does this count as the physician ordering a prescription for the E&M calculator?
Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.
I sent an e-mail to AMA (cptonline@ama-assn.org). Awaiting their response.I disagree that clinicians are always making medical decisions about the prescriptions during medication reconciliation. While they may do so sometimes, I would not consider "medication reconciliation performed" in an EMR to mean they evaluated the appropriateness or dosage of those medications in relation to the problem it is treating.
Example:
Patient being seen at urgent care for cough. Patient is also diabetic and has a history of seizures. The urgent care clinician performs medication reconciliation to ensure OTC Robitussin will not interfere with any other medications previously prescribed. The urgent care clinician is not evaluating whether the neurologist's anti-seizure prescription is the appropriate medication nor the appropriate dose. The urgent care clinician is not evaluating whether the endocrinologist's prescriptions for diabetes are the best treatment for the patient.
I inquired with several clinicians and all agreed that medication reconciliation is not the same as prescription drug management.
I would love to hear some other opinions and references on this.
Hello,
I have a question regarding medication reconciliation as it relates to the determination of E/M complexity.
If a licensed independent provider documents in the patient’s visit note that they have performed medication reconciliation (e.g., “medication reconciliation was performed”), excluding any other activities that qualify as prescription drug management, does medication reconciliation by itself qualify as “Prescription Drug Management” as it relates to the determination of E/M complexity?
Thank you for your assistance.
Sincerely,
I do not feel that it counts towards prescription management but my supervisor insists otherwise which is an odd position to be in. Hopefully I can get this resolved.Doesn't that just mean that the physician reviewed the patients medications with them, not whether or not to continue/discontinue/change the medication? I would need more documentation than that, but just based off of what you have here, I would say no, it is not prescription management.