Are you documenting prescription drug management risk?

CodeCast | Medical Billing and Coding Insights

In this episode of the CodeCast Podcast, Terry addresses a common misconception among medical providers: the belief that simply listing a patient’s medications or repeatedly noting “continue meds” is enough to support a moderate-level evaluation and management visit, such as CPT codes 99214 or 99204. In reality, this documentation alone does not meet the criteria.=

Payers—including MACs, commercial insurers, and Medicaid programs—are increasingly updating their policies to clarify that providers must demonstrate the cognitive effort involved in assessing the risks tied to prescription drug management. Reviewing a medication list without further analysis or context is not sufficient. Instead, documentation should reflect the clinical reasoning, counseling, and risk evaluation discussed with the patient, including potential outcomes related to medication adherence or non-adherence.

Terry breaks down what this means for coding accuracy and compliance, offering insights into how providers can better capture the complexity of prescription drug management in their documentation.

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