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Table of Risk pres. drug management

  1. Smile Table of Risk pres. drug management
    Medical Coding Books
    If the phsyicians states in his documentation to continue on the same prescription drugs. Can that count as drug managment. He is not prescribing anything nor states he is renewing meds at that visit.

  2. #2
    Default Reference
    http://www.aan.com/globals/axon/assets/3427.pdf

    Here is a good reference. Much of the documentation suggests medication management is best associated with psychologists and pharmacists, though I've not seen any clear statement that family practice physicians are excluded or restricted. Managing patients receiving psychotropic drugs would seem to fall under family practice.

    I have found that reviewing patient medications often falls under the MDM section. However, documentation demonstrating the review of patient medications increased the MDM would require more than "continue all current medications."

    I have spoken with our providers and asked them to clearly document their rationale for continueing or changing medications. Even a short statement such as "patient compliance on medication x is good and the desired result on condition y is noted. Therefore medication x will be continued." can demonstrate the physician's thought process.

    Hope this helps

  3. #3
    Default
    Quote Originally Posted by Code-M View Post
    If the phsyicians states in his documentation to continue on the same prescription drugs. Can that count as drug managment. He is not prescribing anything nor states he is renewing meds at that visit.
    It's not necessary that the medication be changed in order for it to count in the MDM; however, the doctor must make it evident that they made a 'decision' to "continue same treatment", by acknowledging what that treatment is, and how it's been working. He doesn't necessarily have to write another prescription that visit, either; as long as his instructions to the patient indicate that they need to be taking it, somehow. (Dosage and drug name shouls be documented somewhere in the note). If the patient doesn't need a refill at the time of service, then the doctor doesn't have to write one, just to get documentation credit.

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