Sorry, are they saying they don't want risk to be a factor in MDM-based coding?
I'm being told by management they(clinicians) don't want to document the risk, because there's a liability in doing that. Many of the clinicians document a differential diagnosis, there could be liability in doing that as well, so why is this more of a liability? It's something coders have to "construct" from the MDM like treatment options.
AMA Article:
Q
Please elaborate on what constitutes Prescription Drug Management is it enough to simply
review a medication list, does there need to be management of the condition, etc.? Also, does
a provider stating “there is a moderate risk for an over the counter medication” enough to
justify a moderate level of risk re: patient management?
A
There is no “blanket” guidance for services to represent specific levels of risk. The physician is
responsible for assessing (and documenting) the level of risk of the services to be performed
including medicine management, (prescription or OTC), based on a specific patient’s risk factors
and the risks typically seen with the drug. For example, an NSAID in a person with kidney
disease or on anticoagulant is of greater concern that most prescription drugs. Simply
reviewing a medication list does NOT constitute prescription drug management.