How to bill drug reconciliation

Q: I spend a  tremendous amount of time reconciling medications with and for my patients. I don’t see a specifi c “data” indicator for this in the decision-making tables. How do I account for this? 

A:

Great question, and you are right, there is no mention of this specifically as medication reconciliation anywhere in the guidelines. 

That said, the website of the Centers for Medicare & Medicaid Services’ Evaluation and Management (E/M) Services Guide contains some language that pertains to Table 1:

“Some important points that should be kept in mind when documenting the number of diagnoses or management options are:

• The initiation of, or changes in, treatment should be documented.

• Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies and medications.”

How this will help you account for the time spent on this task is not so clear, though. If you were to document “medications reviewed and updated for (diagnosis 1, 2, 3, 4, etc.),” you should get the points associated with each stable or worsening problem. This would be best in the assessment and plan (A/P).

An alternative might be to use an indicator from Table 2-review and summary of old records. If you labeled a section of your chart “Med Reconciliation”, either around the A/P or in the Medication area-Review and Summary of Old Records, then you could list the conditions and changes made. This is probably the long way around.

You mentioned the time this takes, and we hear this a lot. Is the patient present, and do you go over the meds with him or her? This could be characterized as counseling, depending on the circumstances.

Q:

 I have a transitional care management (TCM) question. The patient is seen by the primary care physician eight days after hospitalization. There was a phone call within two days of discharge. The TCM code was billed. The patient returns a week later with continued issues related to the problem he was hospitalized for. Can that second visit be billed?

A: Absolutely, as a regular E/M visit, either a 99213 or 99214 code. The TCM code includes only the first visit following the hospitalization discharge. Others can be billed in the same 30-day period and are separately payable.

Those are the likely options as regards the guidelines. But this important and ever-more time-consuming task for primary care has always been somewhat treated just as a cost of doing business. Following the suggestions above can help to change that. 

Q:

 For an established patient, does medical decision-making [MDM] have to be one of the “two out of three” components used to choose the E/M code? The Current Procedural Terminology book doesn’t specify that.

A: Many practices adopt this policy to be certain that all notes are anchored in medical necessity, not just a lot of electronic health record history and exam.

One Medicare medical director has said “if not using the MDM, how are you showing medical necessity for the service?” That person went on to say: ‘If you can answer that question through your medical record documentation by using the other two components; history and exam, then the MDM would not be required.”

The use of decision-making as a required element is a measure of prudence and responsible coding.