Wiki Medication management

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colleen2282

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I have a provider who insists that he has searched the internet for answers and he cannot find anything stating that medication management should include the name of the medication tied to the diagnosis, specifically if he is renewing meds that patient is already taking. below is the documentation that he considers fulfillment for medication management. He states that he already listed current medications patient is taking in the documentation. We have suggested to him that he would need to list the medication for each ailment.

Other chronic diagnosis punctate inner choroiditis and hypertension were reviewed and are stable and the medications for these chronic diagnosis were reviewed and are appropriate given the patient's current condition and will be maintained at current dosage.
 
I gather you're talking about giving credit toward the E/M level for prescription drug management here? If so, I agree with your provider - I have never seen any written guideline that states that specific medications need to be linked to conditions in the not in order to give credit for the provider having done medication management. Normally the patient's current medications are documented in the record and there's no need to require the provider to copy that information over into their note. Would it be better if they did? Perhaps for purposes of clarity it would be, but there's no requirement. The provider is stating that they have done this work and attested to it with their signature, so there's no reason I can think of to penalize them or add to their administrative burden by insisting that they do this extra documentation.
 
thomas7331 said:
I gather you're talking about giving credit toward the E/M level for prescription drug management here? If so, I agree with your provider - I have never seen any written guideline that states that specific medications need to be linked to conditions in the not in order to give credit for the provider having done medication management. Normally the patient's current medications are documented in the record and there's no need to require the provider to copy that information over into their note. Would it be better if they did? Perhaps for purposes of clarity it would be, but there's no requirement. The provider is stating that they have done this work and attested to it with their signature, so there's no reason I can think of to penalize them or add to their administrative burden by insisting that they do this extra documentation.
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thanks so much..
 
I disagree. I believe the drug and the dosage must be linked by the provider to a dx, and be specifically documented.

per Noridian - Ask the Contractor Q&A (emphasis added by me):

Q7. What are the guidelines regarding prescription drug management in the MDM?
A7. Credit is given for prescription drug management when documentation indicates medical decision making for the management of a prescription drug by the physician who is rendering the service. Medical management could include a new drug being prescribed, a change to an existing prescription, verification of any side effects or problems with the drug, or simply refilling a current medication. The drug and dosage must be documented as well as the drug management.
per First Coast (emphasis added by me):
Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication or dosage.
Note: Simply listing current medications is not considered "prescription drug management."
"Prescription drug management" does differ from "drug therapy requiring intensive monitoring for toxicity".
Per the CPT definitions, "drug therapy requiring intensive monitoring for toxicity" is for a drug requiring intensive monitoring which is a therapeutic agent with the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis.
Examples of monitoring that does not qualify includes monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.

per Noridian - FAQs - E/M (emphasis added by me):

When can prescription drug management be credited in the medical decision-making risk of complications chart?
Credit is given for prescription drug management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.
If medications are just listed in patient’s medical record, credit is given for past history.
 
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