Improve patient safety and optimize reimbursement with comprehensive Medication Review. This critical process addresses medication reconciliation, polypharmacy, adverse drug events, and drug interactions. Clinicians and healthcare providers can utilize medication review documentation best practices for accurate medical coding and billing. Learn about medication therapy management, comprehensive medication management, and the importance of patient-centered care in medication review. Explore resources for proper documentation, including clinical guidelines and recommendations for optimizing patient outcomes through thorough medication reviews.
Also known as
Encounter for medication review
Patient encounter specifically for review of medications.
Encounter for other drug counseling
Patient encounter for counseling related to medication use.
Person encountering health services for examination
General health examination, may include medication review as part of the process.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the medication review for a specific condition?
Yes
Is the condition documented?
No
Is it routine/general medication review?
When to use each related code
| Description |
|---|
| Medication Review |
| Adverse Drug Reaction |
| Non-adherence to Medication Regimen |
Lack of documentation specifying reason (e.g., adverse event, therapeutic efficacy) for medication review creates coding and billing ambiguity.
Insufficient documentation of review findings (e.g., changes made, recommendations) impacts accurate code assignment and audit defense.
Lack of proper provider signature on medication review documentation raises compliance concerns and potential claim denial.
Patient presents today for a comprehensive medication review. The patient's current medication list was reviewed in detail, including prescription medications, over-the-counter drugs, vitamins, and herbal supplements. This medication reconciliation was conducted to assess for potential drug interactions, adverse drug reactions, therapeutic duplications, and opportunities for medication optimization. The patient's medical history, including diagnoses such as hypertension, hyperlipidemia, and type 2 diabetes mellitus, was considered during the review. Current symptoms, allergies, and adherence to the medication regimen were also discussed. Potential drug-drug interactions were identified and addressed. Patient education regarding medication management, including proper administration, potential side effects, and importance of adherence, was provided. Recommendations for medication adjustments, including dose adjustments, discontinuation of unnecessary medications, and potential alternative therapies, were discussed with the patient. The plan includes ongoing monitoring of medication effectiveness and safety, with follow-up scheduled to assess response to therapy and address any concerns. This medication review aims to improve patient outcomes, enhance medication safety, and optimize the patient's pharmacotherapy. ICD-10 code Z76.89 (Encounter for other specified aftercare) and CPT code 99605 (Medication therapy management services, initial 15 minutes, new patient) or 99607 (Medication therapy management services, subsequent 15 minutes, established patient), as appropriate, may be considered for billing purposes.