Awareness : Frequently Asked Questions

Evaluation and Management (E/M) FAQs-Key Component Medical Desicion Making

Key Components-Medical Decision Making:

  • Question: During an evaluation and management visit, what constitutes “prescription drug management”?

    Answer: “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage. Note: Simply listing current medications is not considered “prescription drug management.” Source medicare.fsco.com

  • Question: What is required to get credit for prescription drug management? Do I have to stop, start or change a medication dosage, or can I get credit for making the decision to continue a specific medication?

    Answer: Credit is given as long as the documentation clearly indicates that decision-making took place in regard to the medication(s). Note: Simply listing current medications is not considered “prescription drug management.” Source medicare.fsco.com

  • Question: Is prescription drug management enough to establish a moderate level of risk for medical decision-making?

    Answer: The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk. Source medicare.fsco.com

  • Question: In medical-decision making, how does one determine further work-up under “number of diagnoses”?

    Answer: A key element of the medical-decision making category includes management decisions made by the physician to determine a diagnosis and treatment. Evidence of further work-up within documentation would include: indicating a problem is worsening/probable and/or listing possible management options, advice sought, referrals or consultations, and the initiation of or change in treatment. source medicare.fsco.com

  • Question: What is the definition of “self-limited” or “minor” problem vs. “new stable problem?”

    Answer: A new, stable problem is a new problem, which is not worsening. A self-limited or minor problem is of less severity and would be expected to run its course uneventfully. Source medicare.fsco.com

  • Question: Can I refer to someone else’s dictated note and get credit for those parts of the history I reviewed?

    Answer: Yes - review of “old records” is part of the medical decision-making process. Source medicare.fsco.com

  • Question: Can I refer to someone else’s dictated note and get credit for those parts of the history I reviewed?

    Answer: Yes - review of “old records” is part of the medical decision-making process. Source medicare.fsco.com

  • Question: If I review my own previous notes and summarize my findings, would I get credit for “review and summation of old records”?

    Answer: No, credit would not be given for summarizing one’s own previous records. Source medicare.fsco.com

  • Question: When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09”.

    Answer: Yes—when referring to previous notes, specific information must be given regarding when and where. Source medicare.fsco.com

  • Question: When calculating the medical decision-making, are problems defined as “old” or “new” relative to the patient or to the physician?

    Answer: Regarding the medical decision-making component, the designations of “old” and “new” are relative to the physician. Source medicare.fsco.com

  • Question: What does a “self-limited or minor problem” mean? Can you please give some examples?

    Answer: A self-limited or minor problem is one in which the resolution is expected to be fairly rapid, with minimal medical intervention.  Examples would be a cold or an insect bite. Source medicare.fsco.com