Prescription Drug Management in Medical record

Q. During an evaluation and management visit, what constitutes “prescription drug management?”

A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”


Q. What is required to get credit for prescription drug management? Do I have to stop, start or change a medication dosage, or can I get credit for making the decision to continue a specific medication?
A. Credit is given as long as the documentation clearly indicates that decision-making took place in regard to the medication(s).

Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.


Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.



Q. In medical-decision making, how does one determine further work-up under “number of diagnoses”?
A. A key element of the medical-decision making category includes management decisions made by the physician to determine a diagnosis and treatment. Evidence of further work-up within documentation would include: indicating a problem is worsening/probable and/or listing possible management options, advice sought, referrals or consultations, and the initiation of or change in treatment.


Q. What does a “self-limited or minor problem” mean? Can you please give some examples?
A. A self-limited or minor problem is one in which the resolution is expected to be fairly rapid, with minimal medical intervention.  Examples would be a cold or an insect bite.