2016 PQRS Measure #130: Documentation of Current Medications in the Medical Record

DESCRIPTION

Percentage of visits for patients aged 18 years and older for which the eligible professional 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

INSTRUCTIONS

This measure is to be reported each visit during the 12 month reporting period. Eligible professionals 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 reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

DENOMINATOR

All visits for patients aged 18 years and older

AND
Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90957, 90958, 90959, 90960, 90962, 90965, 90966, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92541, 92542, 92544, 92545, 92547, 92548, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97001, 97002, 97003, 97004, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439

NUMERATOR

Eligible professional attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of 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

Definitions:
Current Medications – Medications the patient is presently taking including all prescriptions, over-thecounters, 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 – A patient is not eligible if the following reason is documented:
 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 eligible professional must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible professionals reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible professional documented that the patient is not currently taking any medications

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Current Medications Documented
Performance Met: G8427: Eligible professional attests to documenting in the medical record they obtained, updated, or reviewed the patient’s current medications

OR
Current Medications not Documented, Patient not Eligible
Other Performance Exclusion: G8430: Eligible professional attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible professional

OR
Current Medications with Name, Dosage, Frequency, or Route not Documented, Reason not Given
Performance Not Met: G8428: Current list of medications not documented as obtained, updated, or reviewed by the eligible professional, reason not given
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Documentation of Current Medications in the Medical Record

CMS Disclaimer

If reporting for Physician Quality Reporting System (PQRS) through another Centers for Medicare and Medicaid Services’ (CMS) program (such as the Medicare Shared Savings Program, Comprehensive Primary Care Initiative, Pioneer Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to earn a PQRS incentive and/or avoid the PQRS payment adjustment.

Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, eligible professionals (EPs) should look to the respective quality program to ensure they satisfy the PQRS, Electronic Health Record (EHR) Incentive Program, Value-based Payment Modifier (VM), etc. requirements of each of these programs.

You should not select that you participate in the Medicare PQRS-EHR Incentive Pilot when you attest to this question on the CMS website. The Healthmonix Registry is NOT a qualified submission vendor for clinical quality measures for purposes of meaningful use.