Medicare Compliance & Reimbursement - 2019 Issue 9
You Be the Coder: Learn the Right Way to Report Prescription Refills
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Article Overview
This coding Q&A discusses prescription refill documentation in the context of medical decision making and risk assessment. It compares general CMS guidance with a Medicare contractor policy and explains why payer-specific documentation requirements matter for clinicians, coders, and billing staff reviewing evaluation and management records.
Why This Topic Matters
Accurate documentation of medication management can affect evaluation and management level selection and support compliance with payer expectations. The article helps readers understand the difference between simply listing medications and documenting active medication management.
What You Will Learn
- How prescription refill documentation relates to medical decision making risk assessment
- Why payer policies can affect whether medication management is credited
- What types of documentation support review of ongoing medication therapy
- How general CMS guidance differs from a specific Medicare contractor policy
Who Should Read This
- Medical coders
- Billers
- Physicians
- Clinical documentation staff
- Practice managers
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