"Managing" a patient's prescription drugs is not limited only to the visits at which the prescription is started, stopped, or changed, but would apply to all visits involving
decision-making as regards to the drug, even if the decision is to keep everything the same.
For example, it may be the 3rd follow-up visit after a doctor has presribed a drug, and it is time to re-evaluate whether or not the drug should continue to be taken as it is at present, or whether
- the dosage should be changed
- some other drug should be used instead
- some other management option besides an rx drug should be explored, like a surgical option
In the end, it may be decided to hold off on any changes for now, and for the patient to continue with the current drug. Even though no changes were made, this visit involved prescription drug "management."
This is the view reflected in this AAFP article:
http://www.aafp.org/fpm/20001100/coding.html
Defining risk
Q: The table of risk in Medicare's "Documentation Guidelines for Evaluation and Management (E/M) Services," lists "prescription drug management" in the moderate risk category. I believe this term would cover making a change in a prescribed medicine, but does it also cover making a decision to continue a patient's prescription drug regimen? Likewise, "drug therapy requiring intensive monitoring for toxicity" is listed in the high risk category. I believe this would include checking an INR for a patient on Coumadin, but what other medications and tests might be applicable?
A: Neither the table of risk nor any other part of the documentation guidelines define what "prescription drug management" or "drug therapy requiring intensive monitoring for toxicity" mean. A decision to continue a particular medication might be considered "prescription drug management" since you would be managing the patient's prescription medicine and since a decision to continue a patient's current medication may involve as much risk as a decision to initiate a prescription drug regimen. But whether this example or the second one you gave would fit the descriptions of risk given in the table would be a matter of judgment for both you and any reviewer.
Here's an example of a Medicare contractor (NHIC) agreeing:
http://www.medicarenhic.com/ne_prov/seminars/FairSpring2009QandA.pdf
Question 8. What exactly is meant by prescription drug management in the table of risk? Do I have to add, stop or adjust a drug?
Answer 8. Prescription drug management in the risk table is very easily defined and described. It can be a simple monitoring or a prescription drug (any single drug), assessing the need for the continued use in the plan of care and assessing the need for a change in drug, dose or discontinuing it altogether. There does not need to be a change of any kind and long as the medical record reflects the fact that a prescription drug was considered for the plan of care of a patient. A list of medications alone would not satisfy the medical record reflecting that a prescription drug was assessed for use in the plan of care for that particular date of service. The record should state something like: "continue XYZ at the same dose for (diagnosis)".
First Coast Service Options, Medicare contractor for FL, in their online training module, seems to be a bit more lenient when they say that a provider should document current medications pertaining to the problems the patient is being seen for to receive credit rx drug management. There is no mention of any changes needing to be made in order to receive the credit.
Even though the E/M Guidelines don't expound upon what is meant by prescription drug management, we do get insight into this concept by referring to the "pharmacological management" 90862 CPT code provided for psych MDs to bill when the patient's psychotherapy is being handled by another provider (like a psychologist) who cannot prescribe or manage medications. Of course, "pharmacologic management" and "prescription drug management" are the same concept.
The Summer 92 CPT Assistant says that with pharmacologic management...
...The physician is evaluating how the medication is affecting the patient, determining the proper dosage level and prescribing medication for the patient for the period of time before the patient is next seen.
After evaluating the medication's current effects, the physician may conclude that the dosage is just where it should be and so no changes are made. Credit is given for the decision-making process that happens when a patient is being evaluated for a condition for which they are also currently taking meds for, even if that process results in no changes.
CMS has also created a "lower level" pharmacologic management code for use by psych providers: M0064. Note that the OIG referred to both of these codes as being "medication management" codes:
http://oig.hhs.gov/oei/reports/oei-09-04-00220.pdf
Medication management may be billed under one of two CPT codes: 90862 (psychiatric pharmacologic management) or M0064 (brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic, and personality disorders).
Now see above where code M0064, which is descrbed as a drug "management" code, can involve
monitoring or changing drug prescriptions, not just changing (or starting/stopping).
So even though "management" of a prescription drug isn't explained well in the E/M Guidelines, both CPT and CMS have elsewhere made it pretty clear that evaluating the effectiveness/monitoring current meds qualifies as "managing" a patient's meds.
Seth Canterbury, CPC, ACS-EM
Healthcare Consultant
tscanter26@hotmail.com
