Neurology & Pain Management Coding Alert

What you should know: Physicians frequently recommend a test that the patient ends up declining for one reason or another (for example, financial concerns or reservations about risks). The recommendation itself reflects their clinical judgment and expertise, however. If they determine the test is necessary, either to diagnose or otherwise manage the patient’s condition, that determination can impact each of the amount and/or complexity of data to be reviewed and analyzed section of MDM. As the CPT^® MDM guidelines for this section state, “Ordering a test may include those considered but not selected after shared decision making.”

Factoring in the physician’s order makes sense, because if the physician went through the process to determine the patient needed a particular test, even though the patient didn’t follow through, that still constitutes MDM on the physician’s part.

What to do: You should factor the physician’s order into the MDM or care/treatment plan. Be sure that the doctor documents the fact that they ordered the test, but the patient refused it. If possible, the provider should also record why the patient refused the test. Remember, the more the record expounds on the thought process behind ordering the test, the easier it will be to prove that the physician should receive credit for it.

Also: The patient’s refusal might even increase the complexity of the MDM, as the physician must now consider alternative methods for diagnosis or treatment, or the potential risks of not performing the test.

Understand Elements of Drug Management

Scenario 2: A patient continues their prescription drug treatment with no changes of medication or dosage. You’re wondering what qualifies as prescription drug management, in terms of the moderate-risk level in the complications and/ or morbidity or mortality of patient management element of MDM.

What you should know: CPT^® currently has no explicit guidelines for this. However, you can get a sense of how MDM for this element plays out by looking to Medicare’s directions for prescription drug management.

According to Novitas Solutions, a Part A/B Medicare Administrative Contractor (MAC), you can get MDM credit 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” (www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056).

This indicates you should note the drug and the amount prescribed along with a note showing your provider has decided to either change or not change the prescription drug during the encounter. Simply put, without documenting these three things, you will not be able to justify a moderate level of MDM based on prescription drug management.

This Medicare guidance is similar to guidance included in CPT^® Assistant (Volume 33, Issue 9, 2023), which states, “Similar to MDM regarding a medication (over the counter or prescription), just noting the drug is not management. Deciding to continue or change therapy is management, but the risk is specific to the patient.” Likewise, “Renewing or changing medication in the medication list through an extension or new prescription would represent medication management of the prescribed and OTC medications for that patient…. Therefore, simply reviewing a medication list does not constitute prescription drug management,” according to CPT^® Assistant (Volume 32, issue 11, 2022).

Expert tip: “Sometimes I think we forget to zoom out and see the larger picture. The entire encounter should flow and be consistent with the level of service selected,” explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners LLC in Las Vegas. In other words, no one element should drastically alter the overall level of service.

Keep this in mind when questions such as this one come up.