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2021 MIPS Measure #130: Documentation of Current Medications in the Medical Record

Quality ID 130
eMeasure ID CMS68v10
NQF 0419e
High Priority Measure Yes
Specifications EHR Registry
Measure Type Process
Specialty Allergy/Immunology Audiology Cardiology Clinical Social Work Dermatology Endocrinology Family Medicine Gastroenterology General Surgery Geriatrics Hospitalists Infectious Disease Internal Medicine Mental/Behavioral Health Nephrology Neurology Neurosurgery Nutrition/Dietician Obstetrics/Gynecology Oncology Ophthalmology Orthopedic Surgery Otolaryngology Physical Medicine Physical Therapy/Occupational Therapy Plastic Surgery Preventive Medicine Pulmonology Rheumatology Speech/Language Pathology Thoracic Surgery Urgent Care Urology Vascular Surgery

Measure Description

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.

 

Instructions

This measure is to be submitted at each denominator eligible visit during the 12 month performance period. Merit- based Incentive Payment System (MIPS) eligible clinicians meet the intent of this measure by making their best effort to document a current, complete and accurate medication list during each encounter. There is no diagnosis associated with this measure. This measure may be submitted by MIPS eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS professional or MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

 

Denominator

All visits occurring during the 12 month measurement period for patients aged 18 years and older

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter

AND

Patient encounter during the performance period (CPT or HCPCS): 59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92548, 92550, 92557, 92567, 92568, 92570, 92588, 92626, 96116, 96156, 96158, 97129, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98960, 98961, 98962, 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, G0101, G0108, G0270, G0402, G0438, G0439

 

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.

Definitions:

Current Medications – Medications the patient is presently taking including all prescriptions, over-the- counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.

Route – Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).

Not Eligible (Denominator Exception) – A patient is not eligible if there is documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., 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).

NUMERATOR NOTE: The MIPS eligible clinician must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. MIPS professional or MIPS eligible clinicians submitting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.

This list must include ALL known prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

By submitting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available at the time of the encounter. G8427 should be submitted if the MIPS eligible clinician documented that the patient is not currently taking any medications.

Numerator Options:

Performance Met: Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient’s current medications (G8427)

OR

Denominator Exception: Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., patient is in an urgent or emergent medical situation) (G8430)

OR

Performance Not Met: Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given (G8428)

 

Rationale

According to the National Center for Health Statistics, during the years of 2011-2014, 46.9 percent of patients (both male and female) were prescribed at least one prescription medication with 10.9 percent taking 5 or more medications. Additionally, 90.6 percent of patients (both male and female) aged 65 years and older were prescribed at least one medication with 40.7 percent taking 5 or more medications (2017). In this context, maintaining an accurate and complete medication list has proven to be a challenging documentation endeavor for various health care provider settings. While most of outpatient encounters (2/3) result in providers prescribing at least one medication, hospitals have been the focus of medication safety efforts (Stock, Scott, & Gurtel, 2009). Nassaralla, Naessens, Chaudhry, Hansen, and Scheitel (2007) caution that this is at odds with the current trend, where patients with chronic illnesses are increasingly being treated in the outpatient setting and require careful monitoring of multiple medications. Additionally, Nassaralla et al. (2007) reveal that it is in fact in outpatient settings where more fatal adverse drug events (ADE) occur when these are compared to those occurring in hospitals (1 of 131 outpatient deaths compared to 1 in 854 inpatient deaths). In the outpatient setting, ADEs occur 25% of the time and over one-third of these are considered preventable (Tache, Sonnichsen, & Ashcroft, 2011). Particularly vulnerable are patients over 65 years, with evidence suggesting that the rate of ADEs per 10,000 person per year increases with age; 25-44 years old at 1.3; 45-64 at 2.2, and 65 + at 3.8 (Sarkar, López, & Maselli, 2011). Another vulnerable group are chronically ill individuals. These population groups are more likely to experience ADEs and subsequent hospitalization.

A multiplicity of providers and inadequate care coordination among them has been identified as barriers to collecting complete and reliable medication records. Data indicate that reconciliation and documentation continue to be poorly executed with discrepancies occurring in 92% (74 of 80 patients) of medication lists among admittance to the emergency room. Of 80 patients included in the study, the home medications were re ordered for 65% of patients on their admission and of the 65% the majority (29%) had a change in their dosing interval, while 23% had a change in their route of administration, and 13% had a change in dose. A total of 361 medication discrepancies, or the difference between the medications patients were taking before admission and those listed in their admission orders, were identified in at least 74 patients (Penumarthi et al., 2015). The study found that “Through an appropriate reconciliation programme, around 80% of errors relating to medication and the potential harm caused by these errors could be reduced” (Penumarthi et al., 2015, p. 243).

Documentation of current medications in the medical record facilitates the process of medication review and reconciliation by the provider, which is necessary for reducing ADEs and promoting medication safety. The need for provider to provider coordination regarding medication records, and the existing gap in implementation, is highlighted in the American Medical Association’s Physician’s Role in Medication Reconciliation, which states that "critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes" (2007, p.7). This is because clinical decisions based on information that is incomplete and/or inaccurate are likely to lead to medication error and ADEs. Weeks, Corbette, & Stream (2010) noted similar barriers and identified the utilization of health information technology as an opportunity for facilitating the creation of universal medication lists.

One 2015 meta-analysis showed an association between EHR documentation with an overall RR of 0.46 (95% CI = 0.38 to 0.55; P < 0.001) and ADEs with an overall RR of 0.66 (95% CI = 0.44 to 0.99; P = 0.045). This meta-analysis provides evidence that the use of the EHR can improve the quality of healthcare delivered to patients by reducing medication errors and ADEs (Campanella et al., 2016).

 

Clinical Recommendation Statements

The Joint Commission's 2019 Ambulatory Health Care National Patient Safety Goals guide providers to maintain and communicate accurate patient medication information. Specifically, the section "Use Medicines Safely NPSG.03.06.01" states the following: "Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.”

The National Quality Forum's Safe Practices for Better Healthcare - 2010 Update, states the following: “the healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care” (p. 40).

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