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Wiki Would this count towards prescription drug management?

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mskitaly09

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A provider included in the progress notes "will continue the medicines that we are managing". There is no name or dosage of the prescription. Would this be sufficient documentation to count towards prescription drug management. I had previously advised the provider no and the reason why but the provider states it does. Please provide feedback, thank you!​

 
mskitaly09 said:

A provider included in the progress notes "will continue the medicines that we are managing". There is no name or dosage of the prescription. Would this be sufficient documentation to count towards prescription drug management. I had previously advised the provider no and the reason why but the provider states it does. Please provide feedback, thank you!​

Click to expand...

No, that is not adequate. The physician has to be specific about what medications are being managed, not just vaguely "we'll manage what we're managing."

It might help the physician to remember that the documentation for the visit is a legal, official record and it does a lot more than just "get them credit" to bill a higher E/M level. If another provider or an auditor looked at that note for that visit, is the physician clearly conveying what their thought process was and what was done?

Here's one citation from the AMA. You should be able to find policies from your Medicare MAC that would give the same guidance.


page 4 of PDF

Common Challenges and Opportunities

Appropriate documentation of prescription drug management continues to be an opportunity for many physicians.
Doctors need to know that simply adding the current medication list to the progress note is not adequate. Prescription
drug management is based on documented evidence that the physician has evaluated medications as part of a service
that is provided. Physicians should make a direct connection between the medication that is prescribed to the patient and
the work that was performed on the day of the clinic visit, such as: “Stable hypertension; continue valsartan 10 milligrams,
will refill for 4 months until next follow-up visit.” Simply stating that the medication list was reviewed will not meet the
definition of prescription management.
 
I agree that providers must show their cognitive work, like we all had to show our work in math class.

The CPT Editorial Panel has been asked to create a definition for Rx drug management. Hopefully they'll come through.
 
sls314 said:
No, that is not adequate. The physician has to be specific about what medications are being managed, not just vaguely "we'll manage what we're managing."

It might help the physician to remember that the documentation for the visit is a legal, official record and it does a lot more than just "get them credit" to bill a higher E/M level. If another provider or an auditor looked at that note for that visit, is the physician clearly conveying what their thought process was and what was done?

Here's one citation from the AMA. You should be able to find policies from your Medicare MAC that would give the same guidance.


page 4 of PDF

Common Challenges and Opportunities

Appropriate documentation of prescription drug management continues to be an opportunity for many physicians.
Doctors need to know that simply adding the current medication list to the progress note is not adequate. Prescription
drug management is based on documented evidence that the physician has evaluated medications as part of a service
that is provided. Physicians should make a direct connection between the medication that is prescribed to the patient and
the work that was performed on the day of the clinic visit, such as: “Stable hypertension; continue valsartan 10 milligrams,
will refill for 4 months until next follow-up visit.” Simply stating that the medication list was reviewed will not meet the
definition of prescription management.
Click to expand...
Thank you for your feedback and reference.
 
How do the notes look, is it an office visit type note? Is there somewhere else in the documentation where this might "live" for the service date? Otherwise, no and I agree with the above. But, maybe there is more context missing or more to the note? Can't make a decision based on the small snip info.
 
Hi,

What if the specialist like a GI doctor mentioned the drug name and dosage in the HPI to begin with - for example - the patient is seen in followup today, she is doing well on Omeprazole 40 mg, her GERD is stable and finally, in the Assessment/Plan, the provider documents continue current medications (does not mention again the drug name or dosage) and that diagnostic, management and treatment options were discussed with the patient Does that qualify?
 
Hi, I'd say it doesn't count because I don't see any decision-making related to the prescription.
 
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