There are only a few changes in code selection for Evaluation and Management services using medical decision-making in the 2027 CPT® edition. One significant change is an official description of prescription drug management.
But let’s start with problems. The definition of a stable chronic illness remains the same but some of the text related to that was moved to the definition of a chronic illness with exacerbation progression or side effect of treatment. The wording emphasizes that in order to credit a chronic illness with exacerbation, progression, or side effects of treatment there must be an intent at management. “The intent is to control progression, provide additional supportive care, or manage side effects.” It is a small wording change that implies to me that if there is no intervention or intent to halt the progression or decrease side effects, it would not be considered a chronic illness with exacerbation.
There weren’t any edits to the data section in 2027.
Under the risk of complications and/or morbidity or mortality of patient management there’s a new statement about documentation. “Documentation should reasonably reflect the rationale for the clinical decision, such as therapeutic response (desired, actual, or expected), side effects, patient-specific factors, or monitoring considerations.” There is no discussion about how to interpret the words “documentation should reasonably reflect.”
Prescription drug management has been in the grid from the beginning. But it didn’t have a paragraph in the green pages of the guidelines in the CPT® book. Now it does.
“Prescription drug management: Prescription drug management is met when drug therapy is actively evaluated or directed as part of the plan of care, including initiation, continuation, modification, discontinuation, or consideration of a prescription medicine, when such actions require clinical judgment regarding therapeutic effectiveness, safety, or monitoring. The level of risk is determined by the patient’s clinical factors and the medication’s potential for harm, including the need for counseling, interaction assessment, dose adjustment, or monitoring. An over-the-counter medication may represent moderate or high risk when it unknowns use requires similar clinical judgment as prescription drug management based on patient-specific factors, dosage, or potential adverse effects. The management of multiple medications together may constitute high risk, even if the management of an individual medication is not high risk.”
There’s a lot to consider in this new definition. First it codifies what the AMA has said that prescription drug management includes starting, stopping, renewing, or changing the dose of a medication. It adds to that what I would have assumed, which is the prescription management requires clinical judgment about the effectiveness, safety, or monitoring.
It also codifies what the AMA has long said at its webinars and presentations that an over-the-counter medication could be moderate or high risk depending on the patient’s medical conditions.
The last sentence is “new” news. It addresses the situation where patients are on multiple medications, which if taken alone would likely be considered moderate prescription drug
management. It notes that for patients taking multiple medications, the combined risk of taking those medications may be high even though the individual medications taken alone would not be considered high risk.
Under parental controlled substances there is a new sentence added to the definition. “A parental controlled substance does not automatically constitute high risk, and risk determination should reflect the overall clinical context.”
These last two changes: the addition of a definition for prescription drug management and specifically management of multiple medications which may be considered high risk, and the determination of whether a parental controlled substance is high risk or not and should reflect clinical context lead us back to their statement about documentation on page 12. “Documentation should reasonably reflect the rationale for the clinical decision, such as therapeutic response (desired, actual, or expected), side effects, patient specific factors, or monitoring considerations.”
Based on these changes, I suspect that auditors and reviewers will expect more detailed documentation related to patient-specific factors.