The Documentation Guidelines identify three key components in E/M services: history, exam and medical decision making. When should you count prescription drug management in determing the level of MDM? It may be simpler than you think!
Medical Decision Making (MDM)
MDM itself is divided into three components:
- The number of diagnoses or management options,
- The amount and/or complexity of data to be reviewed and
- The risk of significant complications, morbidity and/or mortality.
Table of Risk
Not stopping there, this table of risk is divided into three sections:
- The presenting problem,
- Diagnostic procedure(s) ordered and
- Management options selected.
Prescription drug management appears in the management options column of the table of risk and is indicated as “moderate.”
Simple, isn’t it? If prescription drug management is selected as the management option, the table of risk indicates moderate. (Of course, to select MDM, you need two of three of the number of diagnoses/treatment options considered, amount of complexity and selection from the table of risk.)
But, considering prescription drug management, the table of risk does not have any qualifications. It doesn’t say, “new prescriptions, not renewals.” It doesn’t say, “Class 1 drugs only.” It doesn’t say, “but, if it’s an easy problem with prescription drug management, don’t count prescription drug management.” It says, simply, “prescription drug management.”
Some coders incorrectly insert their own judgment into the determination of whether to count prescription drug management. I don’t know of any official citation to support that. I do know the official citation that doesn’t support that: The Documentation Guidelines themselves.
Remember what Dr. McCoy says, “The bureaucratic mindset is the only constant in the universe.”
While we are using these complex guidelines, let’s not add to bureaucratic mindset by developing our own guidelines. Use the ones CMS and the AMA developed.
CodingIntel members can download the handout from our webinar or watch the webinar on demand, “To Credit 0r Not to Credit: Auditing E/M Services.“
CodingIntel also offers a comprehensive course, E/M auditing in-depth which includes CEUs.