Email sent to Our Medical Director:
I noticed that ‘and/or checked PDMP’ was added to <Reviewed old records…> check box for Complexity of Data for coding points.
If this is being done as part of Agency protocol, it does not count for coding purposes and should not be included as it may result in up-coding. There is no complexity in decision-making to just follow a protocol.
Unsure how this got changed as this was not the way it was set up per my prior recommendation, and my professional opinion is: this verbiage should be removed and another check box added: <PDMP checked per Agency protocol> that does not link to coding.
I have no problem educating prescribers to check <Reviewed old Records> when they check the PDMP on established patients, not on controlled meds (ie not part of protocol) and document why: “checked PDMP as client has history of Benzo abuse” or “ checked PDMP as client has a SUD Dx” or “client has been using up recent prescriptions prior to renewal date; checking PDMP for possible prescription abuse”. This does show additional ‘work’ on the part of prescribers which may allow for higher coding level.

Experienced E/M coders-please provide input as the Director disagrees with my stance