Prescription Drug Management: The Moderate Risk element of E/M Coding

Appropriate documentation of prescription drug management continues to be an opportunity for many physicians. Doctors need to know that simply adding the current medication list to the progress note is not adequate to include in the level of risk of a moderate visit.

Prescription drug management is based on documented evidence that the physician has evaluated medications as part of a service that is provided. Physicians should make a direct connection between the medication that is prescribed to the patient and the work that was performed on the day of the clinic visit, such as Stable hypertension; continuing Valsartan 10 milligrams, will refill for 4 months until next follow-up visit. Simply stating that the medication list was “reviewed” will not meet the definition of prescription management.

It would have been helpful if 2021 or the updated 2023 Documentation Guidelines, had been defined within the guidelines of Rx management to finally put to rest much of the ambiguity within the auditing world, but unfortunately, AMA did not. Many MACs have published guidance on this topic, and Noridian is pretty clear. Their guidance states: Prescription drug management is the initiation, continuation, discontinuation, or modification of any prescription medication. This does NOT include medications that are OTC and prescriptions that are ONLY prescribed for insurance benefits.

Keep in mind that patient convenience and reimbursement rules NEVER make such determinations. A keyword in the description that causes confusion is “management”. Oftentimes, coders/auditors hear the word management and infer that this would mean a longtime use of a prescription drug; but look up the word.

Management in healthcare is defined as the coordination and administration of tasks to achieve a goal.

How to determine Rx Management:

  • Did it require prescriptive authority?
  • Is the provider of record managing the Rx?
  • A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
  • Documentation of the prescription drug(s) that are being considered and the reason why they are being considered.
  • 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.
  • The patient’s condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.

Again, simply stating in the medical record that the physician renewed a prescription “for a patient” or “continue meds” without further management discussion, does not meet the risk criteria in the Medical Decision-Making table, nor does it warrant an E/M service on its own.

Please remember that prescription drug management is based on the documented evidence in the record showing the provider has evaluated medications during E/M service as it relates to the patient. Simply listing medications that the 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 regarding those medications.

This information has been added to the Medical Decision-Making section of NGS Medicare, and many other MAC websites, have similar language on their Evaluation and Management Frequently Asked Questions web page.