• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

Documentation Needed for Medication Review When No Changes Are Needed

alvesey

New
Messages
2
Best answers
0
A doctor in one of our clinics notes "0 Change" next to the medication listed on the paper E/M tool. We believe we were down-coded in an audit because of this, but cannot find any documentation of what is specifically necessary to show that he does review the medications and in the auditor's words "makes a conscious effort" in NOT changing the patient's medication. I am a very new coder (apprentice). Can anyone please assist me. Thanks!

Annette
 
Messages
173
Best answers
0
Hello alvesey,

When auditing an e/m chart the medication list does not count towards any of the three components of the e/m service. If the provider had documented any prescription drug management (changes in medications for diagnosis the provider was treating at the time of service) that would have counted toward the risk of complication and/or mortality area within the Medical Decision Making component.
 
Top