Does a problem count as a problem addressed if it is for refill only


If the provider sees a patient for a specific illness and refills a medication for a chronic condition that was not addressed, does the moderate risk for medication management still apply or is it strictly related to the condition addressed during the visit?


In short, no. You should not count prescription drug management for risk in MDM if the associated problem is not being addressed today. Only count management components for conditions that were addressed during the encounter – yet another reason to be crystal clear with the documentation. If you are a provider reading this blog, be sure your documentation is clear about the problems you are evaluating and treating today. Such documentation can be the difference between low and moderate complexity decision making.