Prescription Drug Management and the Table of Risk
Evaluation and Management (E/M) services recognize medical decision making as one of three key components to be considered
when selecting a level of service. Medical decision making refers to the complexity of establishing a diagnosis and/or management
options. The risk of significant complications, morbidity, and/or mortality to the patient is one of the measures to be
considered in overall medical decision making. The Table of Risk, found in the 1995 and 1997 CMS Documentation Guidelines,
may be used to help determine whether the risk to the patient is minimal, low, moderate, or high. The assessment of risk is
based upon the disease process and the expected course between the present encounter and the next one. The Documentation
Guidelines instruct that the highest level of risk in any one category in the Table of Risk – Presenting Problem(s), Diagnostic
Procedure(s), or Management Options – determines the overall risk.
Prescription drug management can be found under moderate risk management options in the Table of Risk. But, what is prescription
drug management? It is not clearly defined in the Documentation Guidelines. If we consider risk to patient (not physician
work), we need to think on a broad basis. Because of the way we’re instructed to use the Table of Risk in determining risk
to the patient and overall complexity of medical decision making, one can easily argue that when a prescription is given for a
new problem, this would be moderate risk, even if the nature of the presenting problem itself may be low risk. There is risk to
the patient in initiating a new treatment regimen: the patient’s response to drug treatment is an unknown factor and comes with
inherent risk.
So, how about the scenario for a recurrent, acute uncomplicated illness? The provider prescribes the same drug in the same
manner with little to no documentation to support the decision making. Could it be argued that this is still moderate risk to the
patient? A medical necessity review may find not. Medical decision making is driven by the patient’s presenting problem.
Per the Documentation Guidelines, “The assessment of risk of the presenting problem is based on the risk related to the
disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures
and management options is based on the risk during and immediately following any procedures or treatment.” So, if the
patient has already received the same treatment for the same problem previously, it could be argued that the risk to the patient is
lower than if the selected management option is a new one for the patient. Unless the provider includes some documentation of
the reasoning, the decision making, for management of the recurrent problem with the same medication, the nature of the presenting
problem becomes a determining factor for risk to the patient for previously utilized management options.
A decision not to change a dosage may involve as much medical consideration, deliberation and risk management as prescribing
a medication for the first time. If a simple refill is offered, the risk is lower to the patient. Again, documentation of management
of the patient’s prescription medications is key.
This type of rationalization can be daunting for providers, coders and auditors who struggle with leveling each service on an
individual basis, as supported by the documentation. Too often, the rules are applied mechanically toward getting the “right
number of elements” to level a service without consideration for the context of the service and the concept of medical necessity.
The relationship between the clinical judgment of the provider and the nature of the patient’s presenting problem(s) is integral to
coding and documentation, and the basis for supporting the medical necessity of the service.
If determining the level of risk associated with prescription drug management is an area of confusion and inconsistency in your
coding department or practice, consider defining what prescription drug management means to your group. There needs to be an
objective method for determining risk to patient so that prescription drug management is applied consistently by providers and
coders alike. Gather input from your providers and your payers. Then, establish a policy by which prescription drug management
is determined and measured and educate to that end.
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