Question: In a practice with practitioners who see a lot of patients with Alzheimer's disease and dementia who live in an assisted-living facility, all of the patient's medications must be prescribed, including over-the-counter (OTC) medications, so that the facility may administer them. Would management of prescribed OTC medications be considered prescription management in the MDM element for risk when choosing the appropriate E/M code? ...
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Article Overview
This Q&A addresses evaluation and management documentation for patients with Alzheimer’s disease or dementia who live in assisted-living facilities and require medications to be prescribed for administration. It discusses how medication management is considered within the risk element of medical decision making, including the role of prescription and over-the-counter drugs, the importance of patient-specific risk factors, and how the guidance relates to the 2021 E/M changes. The article is most relevant to physicians, coders, and compliance staff who document or audit E/M services involving medication management.
Why This Topic Matters
Medication management is a common part of E/M leveling, and documentation needs can differ when facilities administer both prescribed and over-the-counter medications. Understanding the general guidance helps clinicians and coding staff support accurate risk assessment and compliant E/M documentation.
What You Will Learn
- How medication management is considered within the MDM risk element for E/M services.
- Why over-the-counter medications may require individualized risk assessment in certain care settings.
- How patient-specific factors influence the documentation of medication management.
- How the discussion relates to guidance associated with the 2021 E/M updates.
Who Should Read This
- Physicians
- Coders
- Medical billers
- Compliance staff
- Clinical documentation specialists
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