A doctor in one of our clinics notes "0 Change" next to the medication listed on the paper E/M tool. We believe we were down-coded in an audit because of this, but cannot find any documentation of what is specifically necessary to show that he does review the medications and in the auditor’s words "makes a conscious effort" in NOT changing the patient’s medication. I am a very new coder (apprentice). Can anyone please assist me. Thanks!

Annette