Wiki prescription drug management for MDM leveling

[mnuhfer04]

Good morning! I work for a primary care office. Our providers will typically document "refill medications per emr" in the patients SOAP note (the do not list each medication in the note). Now I can see each medication that was refilled in the chart. Would this count as "prescription drug management" for MDM? I am getting some conflicting information. I have read articles that say yes, it counts, and some that say no that it actually has to be in the note itself. I would love some input on this. Thanks!

 

[1formissy]

We would need to know what Rx's were refilled. I recommend the provider document the Rx's that were refilled to help support management vs just documenting the Rx list. Outside audit would not have the access to see the Rx's that were refilled in the chart. Each medical record must be a stand-alone record and support itself in Audit. Since the complexity is moderate for management strong documentation is crucial.

 

[mnuhfer04]

We would need to know what Rx's were refilled. I recommend the provider document the Rx's that were refilled to help support management vs just documenting the Rx list. Outside audit would not have the access to see the Rx's that were refilled in the chart. Each medical record must be a stand-alone record and support itself in Audit. Since the complexity is moderate for management strong documentation is crucial.

Thank you Missy, that makes sense, I appreciate your feedback.

 

[upadhyaymini]

Yes it should be " prescription drug management". Most of the time they mention in HPI .If you cant find anywhere , u could ask them the name of the medication for refill.
"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/dosage.
i hope it helps.

 

[mnuhfer04]

Yes it should be " prescription drug management". Most of the time they mention in HPI .If you cant find anywhere , u could ask them the name of the medication for refill.
"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/dosage.
i hope it helps.

It does, thank you! I just asked the providers to document in the note which medications they are refilling, they said no problem.