Prescription Drug Management

Question:

Every patient I see is in pain, and I discuss prescription medications (primarily prescription NSAIDs, Neurontin, and/or muscle relaxers) with almost every patient. If I document “discussed prescription drug management with Mobic, patient defers and will continue Motrin OTC as needed.” Is this prescription drug management?

Answer:

If this is a true clinical management option for this unique patient based on their history, pain level, the number of times you have seen them, imaging, and the patient is not responding to OTC meds, and you determine Mobic is the best next course of treatment for the patient, and they still decline it, this can support prescription drug management. You are still recommending something that has a risk to the patient. This is from the clinical standpoint, which must be clearly documented in the note.

Be aware, many payors have increased scrutiny in this area and may not see it the same way. It can go both ways, so you must be careful. If you routinely do this for every patient to increase your code level and submit all of these as level fours, you may be at risk and set yourself up for an audit from a payor.

Prescription drug management involves a prescription-strength drug that the patient must go to the pharmacy to get. The name, dosage, strength of the drug, and how to take it, along with any rationale for why it is prescribed at the time of the visit, also need to be documented. Payors want to see this documentation in the plan of care. Prescription drug management involves the risk that you take prescribing and the risk to the patient taking the medication.

Refilling a current prescription does not automatically equate to a Moderate level of MDM. The billing practitioner must document the rationale for continuing the medication for the patient at the visit (e.g., the patient’s pain is well-controlled on x mg at this time, and he/she will continue the current dose).

*This response is based on the best information available as of 1/16/25.

History and Examination requirement for E/M services

Question:

I have been practicing for many years and am confused about the E/M guidelines since the changes were made a few years ago, mainly for my office services 99202-99215.  My coder says I should document an history and examination, but I don’t think this is required anymore.  Am I correct?

Answer:

The evaluation and management service levels are no longer determined by history and examination but are based on medical-decision making or Time except for emergency department visit codes (99281-99285), which do not contain a time component. However, a clinically relevant history and examination are required based on the practitioner’s clinical judgment. It is essential to tell the “story” of the patient’s clinical picture in the documentation. The history and examination support the medical necessity for the visit and provide a more complete representation of the patient’s condition for continuity and coordination of care with other clinical practitioners.

*This response is based on the best information available as of 1/2/25.

Counting the Number and Complexity of Problems Addressed

Question:

Would cervical and lumbar radiculopathy count as one or two problems, and are they considered acute, chronic, stable, or not stable on the table of risk?

Answer:

Good questions! First, the number of problems would be two since these are different body parts, and each will require its own diagnosis and treatment recommendation.

The next is issue is, are the presenting problems acute or chronic, and that will require a good history of present illness, detailing how the problem presented. Was it an injury? Is it degenerative, so by the very nature of degenerative disease it is chronic. An accurate selection of where the problems “fit’ within the problem element cannot be determined without a good history.

*This response is based on the best information available as of 12/19/24.

Risk of Patient Management

Question:

Is a decision to NOT perform an injection with risk factors discussed “moderate” risk?

Ex: The patient has done 6 weeks of physical therapy for their spinal stenosis, which has provided some relief, but he is not at the treatment goal. We discussed performing a lumbar epidural steroid injection with the risks of the procedure, including bleeding, infection, and nerve damage. The patient is a diabetic, and we discussed the risks of the corticosteroid injection elevating blood glucose levels. After this discussion, he elected to continue PT and avoid injection at this time.

Answer:

Yes, a decision for treatment, in this case, an epidural injection, is a medical decision made by the physician. Even if the patient defers this recommendation, it still constitutes a medical decision and one with documented patient and procedure risks.

Per CPT Guidelines:

For the purposes of MDM, the level of risk is based upon the consequences of the problem (s) addressed at the encounter when appropriately treated. Risk also includes MDM for initiating further testing, treatment, and/or hospitalization.

1) The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified healthcare professional during the reported encounter.

2) Includes the possible management options selected and those considered but not selected after sharing MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care.

*This response is based on the best information available as of 12/5/24.

Number and Complexity of Problems Addressed

Question:

I see a lot of patients with chronic pain and other issues. What defines “stable” vs. “exacerbation or progression”?

Answer:

Number and Complexity of Problems Addressed

Per the CPT guidelines, ‘stable’ for the purposes of categorizing medical decision-making is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

A chronic illness with exacerbation, progression, or side effects of treatment is a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control the progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care.

For all E/M codes, while it doesn’t contribute to code selection, documenting the history of the present illness (HPI) is crucial documentation. The provider must document each problem addressed and indicate stable, acute, chronic, exacerbation, etc., for each problem. Incorporate the terms exacerbation (getting worse) and severe exacerbation (getting significantly worse, requiring significant treatment changes) in your assessment when applicable. Be sure to document a recommendation (plan of care) for each problem addressed (i.e., stable, make changes, order additional testing).

*This response is based on the best information available as of 11/17/24.

Risk of Patient Management

Question:

I am a Pain Management Physician. I have a patient with lumbar spinal stenosis who has completed two months of physical therapy and 2 epidural steroid injections, but significant pain still persists. Since extensive conservative management has failed to provide adequate relief, I now recommend a surgical consultation with a spine physician. I document, “We discussed risks of surgery including bleeding, infection, nerve damage as well as patient-specific risks including hypertension. After discussing the risks and benefits of surgery, the patient elects to continue conservative management”. Does this count as a decision for surgery (moderate risk)? I am not clear on if I can make a “decision for surgery” as a non-surgical physician.

Answer:

Thank you for your inquiry. In answer to your question, no, this would not be a decision for surgery on the MDM table of risk. You are not the surgeon; you are considering a surgical consultation. The surgeon is the provider who makes the decision for surgery.

*This response is based on the best information available as of 10/17/24.