Performance Measure: Clinical Information Reconciliation

Measure: For at least one transition of care or referral received or patient encounter in which the MIPS ECClosed Eligible Clinician: a Medicare provider who qualifies for MIPS participation has never before encountered the patient, the MIPS eligible clinician performs clinical information reconciliation. The MIPS eligible clinician must implement clinical information reconciliation for the following three clinical information sets: (1) Medication. Review of the patient’s medication, including the name, dosage, frequency, and route of each medication. (2) Medication allergy. Review of the patient’s known medication allergies. (3) Current Problem list. Review of the patient’s current and active diagnoses.
Denominator The number of transitions of care or referrals during the performance period for which the MIPS eligible clinician was the recipient of the transition or referral or has never before encountered the patient.
Numerator The number of transitions of care or referrals in the denominator where the following three clinical information reconciliations were performed: medication list, medication allergy list, and current problem list.

To be included in the denominator:

  • Patient must be identified as a transition of care patient in an eligible encounter during the performance period

    • Eligible encounters for this measure are: Multi-System, Exam, Urgent Care, Reconciliation, Initial OB, Visit, OB Follow Up Visit, and OB Postpartum Visit

    • Encounter must be finalized by the EC

OR

To identify a patient as a transition of care patient, go to the Coding tab of the eligible encounter and select the Encounter Related to Transition of Care into Clinic checkbox.

  1. Go to Chart > Chart Tools > C-CDA Reconciliation or Tools > C-CDA Reconciliation
  2. Click Import to choose a C-CDA file
  3. Select the file and click Open
  4. Verify patient selected matches the file chosen and select the I have verified the document belongs to the above patient checkbox
    1. If reconciling from the Tools menu, click Select to search for and select a patient, then select the verification checkbox
  5. Click Next
  6. Reconcile the file by selecting the checkbox(es) next to the problems, allergies, and medications to be incorporated into the patient’s chart
    1. At least one problem, allergy, or medication must be selected to complete the reconciliation
  7. Click Review
  8. Review the incorporated data for accuracy and click Sign to complete the reconciliation
  1. Select a message with a C-CDA file attachment from the PPDX Inbox
  2. Click View or double-click the message to view its contents
  3. From the Attachments section, select the checkbox next to the C-CDA file to be reconciled
  4. Click Import
  5. Click Select to search for and select a patient and select the I have verified the document belongs to the above patient checkbox
  6. Click Next
  7. Click Reconcile
  8. Reconcile the file by selecting the checkbox(es) next to the problems, allergies, and medications to be incorporated into the patient’s chart
    1. At least one problem, allergy, or medication must be selected to complete the reconciliation
  9. Click Review
  10. Review the incorporated data for accuracy and click Sign to complete the reconciliation or click Start Reconciliation Encounter to document additional information in a Reconciliation encounter type
    1. If Start Reconciliation Encounter is selected, the encounter must be finalized by the EC

From the Attachments section of an open message, select the C-CDA file to be reconciled and click View to view the contents of the file prior to beginning a reconciliation.

To be included in the numerator:

  • Patient must have a clinical reconciliation performed in an eligible encounter in which the patient was identified as a transition of care during the performance period
    • Eligible encounters for this measure are: Multi-System, Exam, Urgent Care, Reconciliation, Initial OB, Visit, OB Follow Up Visit, and OB Postpartum Visit
    • Encounter must be finalized by the EC

OR

  • Patient must have a clinical reconciliation of a C-CDA performed by the EC during the performance period
  1. From the Allergies/Meds Hx tab, select the Allergies Reviewed checkbox
  2. From the Allergies/Meds Hx tab, select the Medications Reviewed checkbox or the Patient Takes NoMedications checkbox or from the Medications tab, select the Medication reconciliation performed checkbox
  3. From the Assessment tab, select the No active problems checkbox or select the checkbox in the Assessed column for any active diagnosis or add a new diagnosis using the Add (Favorites) or Add (Master List) button
    1. Selecting any active diagnosis and then selecting the Inactivate or Resolve button will count toward reconciling current problems
    2. Selecting any active diagnosis and then selecting the Change button and updating and saving information in the Chronicity, Severity, Progress, Anatomical location site, or Note field will count toward reconciling current problems
    3. Selecting any active diagnosis and then selecting the Map SNO button and mapping to a SNOMED CT code will count toward reconciling current problems

The clinical reconciliation of a C-CDA can be performed from the C-CDA Reconciliation tool or the PPDX Inbox using the steps outlined in the denominator.

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