CMS 68v15: Documentation of Current Medications in the Medical Record
| Measure: Percentage of visits for patients for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter | ||
| Measure Type | High Priority Measure | Scoring |
| Process | Yes | A higher percentage indicates better quality |
| Denominator | All visits occurring during the 12 month measurement period |
| Numerator | Eligible clinician attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter |
| Denominator Exceptions | Documentation of an acute health crisis where time is of the essence and delay of treatment would jeopardize the patient's health status |
| Denominator Exclusions | None |
Denominator
Patients who meet the following criteria will be included in the denominator:
- Have at least one eligible encounter during the Measurement Period finalized by the EC
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, 92549, 92550, 92557, 92567, 92568, 98270, 92588, 92626, 92650, 92651, 92952, 92653, 96116, 96156, 96158, 97129, 97161, 97162, 97163, 97164, 97165, 97166, 67167, 67168, 97802, 97803, 97804, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98960, 98961, 98962, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99236, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385, 99386, 99387, 99395, 99396, 99397, 99424, 99491, 99495, 99496
HCPCS: G0101, G0108, G0270, G0402, G0438, G0439
Procedure Codes Eligible for Denominator
To document a denominator-eligible visit as a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add the code listed below:
CPT: 92622
Order Status must be marked as Complete and encounter must be finalized by the EC.
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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