Documentation for Prescription Drug Management

What documentation is required to show a provider is performing prescription drug management? It has been a question since the changes to the Office or Other Outpatient Services codes was announced by the American Medical Association (AMA) in 2021. The table Elements of Medical Decision Making, which was introduced with the changes, has a “Risk” column that includes four qualifiers. The qualifiers include: two that address surgical decision making; one that addresses social determinants of health; and one that addresses prescription drug management (PDM).  

It seems that prescription drug management would be the most used one by the widest group of physicians since it is not restricted to surgical patients or patients with circumstances identified in the social determinants of health codes. Also, since many patients are on medications or placed on medications at visits, it seems like a natural choice when looking to bill the highly coveted level 4 office visit which required two areas on the Elements table at a moderate level. This moderate level in the risk column needs to be shown in the documentation in order to demonstrate and compensate the physician for the additional work.      

If one looks at the Code and Guidelines Changes documents released by the AMA in 2021, and again in 2023 when additional revisions to the Evaluation and Management (E&M) codes were made, there is detailed information to help you understand terms like “analyzed,” “unique,” and “discussion.” Unfortunately, there is nothing to assist with better understanding documentation requirements for PDM.    

Doing some research, I found a document the AMA released prior to the 2021 changes to help with the transition to the new guidelines. Under the heading Common Challenges and Opportunities, it states the following:

Appropriate documentation of prescription drug management continues to be an opportunity for many physicians.  Doctors need to know that simply adding the current medication list to the progress note is not adequate.  Prescription drug management is based on documented evidence that the physician has evaluated medications as part of a service that is provided.  Physicians should make a direct connection between the medication that is prescribed to the patient and the work that was performed on the day of the clinic visit, such as ‘stable hypertension, continue valsartan 10 milligrams, will refill for 4 months until the next follow up visit.’  Simply stating that the medication list was reviewed will not meet the definition of prescription management.  

Prior to the 2023 changes, the AMA released a document of attendee questions that were submitted during a CPT webinar on upcoming E&M changes. The document states:

There is no ‘blanket’ guidance for services to represent specific levels of risk.  The physician is responsible for assessing (and documenting) the level of risk of the service to be performed including medicine management (prescription or OTC) based on a specific patient’s risk factors and the risks typically seen with the drug.  For example, an NSAID in a person with kidney disease or an anticoagulant is of greater concern than most prescription drugs.  Simply reviewing a medication list does NOT constitute prescription drug management.

One can begin to get the picture that PDM, as defined by the AMA, needs to be shown in documentation that is unique to the patient for that date of service and for a particular medication in showing the patient’s risk and the risk of the medication being considered.  

A few Medicare Administrative Contractors (MACs) have placed information on their websites about PDM, offering additional insight. Noridian Medicare states, “documentation for prescription drug management would need to show the work and/or risk involved by the billing provider when managing a prescription.” NGS Medicare includes more detailed information on their website stating:  

Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.  

They also indicate that “in order to count prescription drug management there must be documentation of at least one of the following factors:

• A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
• Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
• Documentation of a decision to initiate a new prescription drug(s).  
• Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
• The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.”

A collaboration workgroup from CGS Medicare compiled questions and answers from their educational events.  In this document their definition of prescription drug management is as follows:

Prescription drug management does not require a new drug, a new dosage, or a discontinuation of a current prescription. The medical record will show the physician work to determine the medical necessity of the prescription drugs. An encounter documented as only a prescription refill without documentation of a problem addressed would not suffice. The AMA defines a problem addressed in part as “A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.” You can also count prescription medications considered but not given. There could be patient choice, possible drug interactions, etc.  Prescription drug management does not include drugs injected during the current or subsequent encounter.”

While these three MACs provide information on their websites that reflect the sentiment that a more narrative note is needed about the patient and the medication being managed, some MACs are not as clear. Novitas’ website includes the following limited information:  

Credit is given for prescription drug management in the risk of complications and/or morbidity or mortality of patient management when documentation indicates medical management of the prescription drug by the physician who is rendering the service. Medical management includes a new drug being prescribed, a change to an existing prescription or simply refilling a current medication. The drug and dosage should be documented as well as the drug management.”

As you consider the information from both the AMA and the MACs, you should note that statements such as “continue medications” or “refill medications” are insufficient. The documentation of the risk of the medication to that specific patient, including the patient’s risk factors and benefits, require customized wording that cannot be part of a pre-populated paragraph inserted into the patient record.    

One often asked question is “what about over the counter medications?” Looking at the guidance from the AMA, it mentions equal consideration for both OTC and prescription medications. It remains the physician’s responsibility to assess and document the level of the patient’s risk and benefit for a specific medication.    

While this may not be a popular opinion, my strong advice is that physicians look at their documentation as more individualized rather than templated. Typing sentences (free texting) to give information specific to a patient on a specific date is needed. Tell the story of the care for the patient that is in front of you that day. What is unique to that patient and his or her medications? In a world of electronic health records with drop-down menus of pre-determined wording, smart phrases, and the copy forward of information, this is an area of your documentation that needs patient and date-specific personalization. At a minimum, documentation should include the date of service, the medication(s), and the risks and benefits specific to the patient. Documentation of prescription drug management is part of a higher level of service at moderate medical decision making. As such, proper documentation is key.