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Question: A provider advised a patient to begin a medication and instructed them on the correct way to take it, including advising them of possible interactions with another drug they鈥檙e currently prescribed. After this discussion, the patient said that they actually didn鈥檛 want to take the newly prescribed medication. Can it still count as a data element for the choosing the correct level of the evaluation and management (E/M) service?

Montana Subscriber

Answer: According to the Medicare Administrative Contractor (MAC) , providing this type of service can count toward risk, even if the patient declines the medication.

Noridian says that such a situation can still contribute as a data element for an E/M service: 鈥淵our medical decision for the patient is to start a medication therapy. Documentation would show the patient's decline and any adjustments the physician made to the plan of care.鈥� 

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, 星空入口