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Medical Decision Making and the Impact of Prescription Drug Management

Medical decision-making (MDM) is one of the key components used to determine the level of service for Evaluation and Management (E/M) coding. Since 2021, the American Medical Association (AMA) and CMS have emphasized MDM (or time, when applicable) as the primary factor for selecting E/M levels.

MDM consists of three distinct elements, and the overall level is determined by meeting or exceeding two of the three elements.

Element What It Means
1. Number and Complexity of Problems Addressed The number and severity of conditions evaluated during the encounter
2. Amount and/or Complexity of Data Reviewed and Analyzed Includes labs, imaging, external records, and discussions with other providers
3. Risk of Complications and/or Morbidity or Mortality of Patient Management Based on medical decisions such as starting medications, ordering procedures, or managing comorbidities

There are four recognized levels of MDM:

  • Straightforward
  • Low
  • Moderate
  • High

Each level reflects increasing complexity in medical thought and patient risk.

Prescription Drug Management

Prescription drug management applies to the Risk element of MDM and may support a moderate level of risk when the provider demonstrates active management of a patient's medication therapy. Prescription drug management alone does not establish the final MDM level. Documentation must also support the applicable problems and/or data elements necessary to determine the overall MDM level. 

Examples of prescription drug management may include:

  • Initiating a prescription medication. 
  • Continuing an existing prescription after evaluating the patient's condition. 
  • Adjusting medication dosage, frequency, or duration. 
  • Discontinuing a medication due to clinical concerns, side effects, or treatment goals. 
  • Providing or managing sample medications. 
  • Considering prescription medication but deciding against its use due to patient-specific factors, potential drug interactions, contraindications, or patient preference.

To qualify for credit under MDM, documentation should clearly identify:

  • The medication involved. The drug name and dosage must be specified.
  • The provider's medical decision (e.g., “continue,” “increase,” “discontinue”).
  • The reason for the decision.
  • How the decision relates to the patient's current condition and treatment plan.

Important Considerations

Prescription drug management does not require:

  • A new prescription.
  • A medication dosage change.
  • Discontinuation of medication.

The provider's evaluation and management of prescription therapy may support prescription drug management when appropriately documented.

An encounter documented solely as a prescription refill, without documentation of a problem addressed or managed, may not support prescription drug management for MDM purposes. 

Over the counter (OTC) medications do not qualify as prescription drug management. However, documentation that demonstrates management of prescription medications in conjunction with an OTC medication may support prescription drug management when clinically appropriate.

Drug Therapy Requiring Intensive Monitoring for Toxicity

Certain medications may qualify for the high-risk category under the Risk element when they require intensive monitoring for toxicity. The monitoring is performed to assess potential adverse effects of the medication and not primarily to assess therapeutic effectiveness. 

Drug therapy requiring intensive monitoring for toxicity includes:

  • A therapeutic agent that has the potential to cause serious morbidity or death.
  • Monitoring is accepted practice for the medication.
  • Monitoring performed through laboratory testing, physiologic testing, or imaging.
  • Long-term monitoring that typically occurs at least quarterly.
  • Monitoring that directly impacts patient management decisions. 

Monitoring by history or physical examination alone does not qualify as intensive monitoring for toxicity. 

Examples That May Support

Examples may include:

  • Monitoring for cytopenia during treatment with antineoplastic agents.
  • Intensive monitoring of electrolyte abnormalities or renal function in patients undergoing active diuresis.
  • Other medication-specific monitoring performed to identify potentially serious adverse effects. 

Examples That Typically Do Not Support

Examples not considered intensive monitoring for toxicity include:

  • Routine glucose monitoring during insulin therapy when monitoring is performed primarily to assess therapeutic effectiveness.
  • Annual laboratory monitoring for stable patients receiving maintenance medications.
  • Monitoring performed solely through patient history or examination. 

Data Element Documentation Reminders

Because prescription drug management supports only the Risk element of MDM, providers should ensure documentation also supports the appropriate Problems and/or Data elements necessary to establish the overall MDM level. 

External Notes

Review of notes from the same physician or from physicians of the same specialty within the same group practice does not qualify as review of external notes. External notes are typically records from a different physician, qualified health care professional, facility, or health care organization. 

Tests Ordered and Reviewed

Ordering and reviewing the same test count as a single data element. Tests ordered during an encounter are presumed to be analyzed when the results are available. 

Independent Interpretation

Independent interpretation may be counted when the provider personally interprets a test, image, tracing, or specimen and the professional interpretation is not separately reported. Documentation should clearly support the provider's personal interpretation and how it was used in patient management. 

Independent Historian

An independent historian may contribute to the Data element when additional history is obtained from an individual such as a parent, guardian, caregiver, spouse, witness, or surrogate because the patient cannot provide a complete or reliable history or when additional confirmation is necessary. Documentation should identify both the historian and the reason the information was required. 

Documentation Tips

To support accurate MDM selection, documentation should clearly demonstrate:

  • The problems addressed during the encounter.
  • The data reviewed and analyzed.
  • The provider's assessment and treatment plan.
  • Medication management decisions and clinical rationale.
  • Patient-specific risk considerations that affected management decisions. 

Remember, prescription drug management is one example within the Risk element of MDM. The final MDM level is determined by evaluating all applicable elements and selecting the level supported by at least two of the three MDM categories. 

 

References