Wiki Medication management

[Gator]

Office disagreement.
ASSESSMENT: Benign essential hypertension I recommended at this time he be consistent taking his amlodipine in losartan. I also recommended he get serious about losing some additional weight.
My view = This is NOT medication management and considered only a statement. However, adding something such as "continue taking current. . . & be consistent in taking. . . " could be counted as medication management. (Medication & doses are listed elsewhere in note as well as "reviewed all medications" in HPI.) By adding continue taking that shows provider has reviewed these medications for this condition and wants him to keep taking them as currently prescribed.

 

[csperoni]

As almost always, it could be documented more thoroughly, but I would consider this as prescription drug management. Here is what NGS says about it:

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.


To me, the statement "I recommended at this time he be consistent taking his amlodipine...." demonstrates MDM regarding the prescription. The "recommended" is what cinches decision making (in my view) vs a statement listing medications.