Wiki E/M level 4 requirements

[colebk]

Hi all - Provider saw new pt for 1 undiagnosed new problem with uncertain prognosis. She gave pt 3 months of birth control samples, but did not send a prescription. Do the samples qualify as "medication management" or does it need to be an actual prescription sent to pharmacy? Thanks for any insight you can offer.

 

[csperoni]

The provider gets credit for making the medical decision to start, continue, discontinue or adjust a prescription, not for the administrative work of transmitting a prescription to the pharmacy. The documentation should still include the name and dosage/instructions of the prescription. It it says "samples of OCP given" without the name/dosage, then I would not count it, AND instruct my clinician about better documentation moving forward.
Here is what my MAC, NGS says:

1. Please define prescription drug management relative to MDM.
   
   Answer: In order to count prescription drug management there must be documentation of at least one of the following factors:
   1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
   2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
   3. Documentation of a decision to initiate a new prescription drug(s).
   4. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
   5. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.

Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

 

[colebk]

Thank you - that was extremely helpful!