Documentation Needed for Medication Review When No Changes Are Needed

alvesey

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Location
Cedar Rapids, IA
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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
 
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174
Location
Durham, NC
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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.
 
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