CMS 68v9: Documentation of Current Medications in the Medical Record
| Measure: Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration | ||
| Measure Type | High Priority Measure | Scoring |
| Process | Yes | A higher percentage indicates better quality |
| Denominator | All visits occurring during the 12 month measurement period for patients aged 18 years and older |
| Numerator | Eligible professional or eligible clinician attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency and route of administration |
| Denominator Exceptions | Medical Reason: Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status |
| Denominator Exclusions | None |
Denominator
Patients who meet the following criteria will be included in the denominator:
-
Age is ≥ 18 years at the beginning of the Measurement Period
AND
- Have at least one eligible encounter during the Measurement Period finalized by the EC/EP
Encounter Codes Eligible for Denominator
CPT: 59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97127, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99236, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385, 99386, 99387, 99395, 99396, 99397, 99495, 99496
HCPCS: G0101, G0108, G0270, G0402, G0438, G0439, G0515
Denominator Exceptions
A patient will be counted as an exception if a medication reconciliation was not performed due to an urgent medical situation.
To document an exception, go to Encounter > Medications and select the Medication Reconciliation Not Performed Due to Urgent Medical Situation checkbox.
Numerator
A patient will be counted in the numerator if a medication reconciliation is performed at every eligible encounter during the Measurement Period.
To document a medication reconciliation was performed for the patient, go to Encounter > Medications and select the Medication Reconciliation Performed checkbox.
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