• Measure 130: Documentation of Current Medications in the Medical Record


    Updated January 2018.

    Reporting Options: 

    • IRIS Registry for EHR: groups and individuals
    • IRIS Registry for manual data entry: groups and individuals
    • EHR through your vendor (if offered): groups and individuals
    • Claims-based reporting: individuals only

    Measure Type: Process - High Priority

    2018 additions in red

    Instructions: This measure is to be submitted at each denominator eligible visit during the 12 month performance period, for patients aged 18 years and older, for which the physician 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.

    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).

    To Which Patients Does the Measure Apply?

    Denominator: All visits for patients aged 18 years and older.

    There are two criteria for inclusion of a patient into the denominator.

    1. Patient characteristics: Description located in “Instructions” (see above).
    2. Procedure codes (CPT and HCPCS): Codes located in “CPT Codes” and “HCPCS Code.”

    The quality measure also has exclusions for the denominator.

    Diagnosis Codes

    This measure does not require a specific diagnosis to be submitted during the encounter.

    CPT Codes

    2018 additions in red

    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, 99024, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, 99281, 99282, 99283, 99284, 99285, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0101, G0108, G0270, G0402, G0438, G0439

    2018 deletion of CPT code 97532

    Denominator note: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule. These non-covered services will not be counted in the denominator population for claims-based measures.

    How to Report the Measure

    Claims and IRIS Registry Manual Reporting

    Numerator: Eligible professional or eligible clinician 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.

    Exclusion: 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 on the date of the encounter. This reason must be documented.

    2018 additions in red

    Numerator note: The eligible clinician must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible clinicians submitting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. 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 eligible clinician documented that the patient is not currently taking any medications.

    HCPCS Codes

    • Performance met (patient included in numerator and denominator): G8427 Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient’s current medications
    • Denominator exclusion (patient not included in numerator or denominator): G8430 Eligible clinician 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 clinician
    • Performance not met (patient not included in numerator, but included in denominator): G8428 Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given

    Clinical Recommendation Statements: The Joint Commission's 2015 Ambulatory 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: "Maintain and communicate accurate patient medication information. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future." (Joint Commission, 2015, retrieved at: http://www.jointcommission.org/assets/1/6/2015_NPSG_AHC1.PDF). The National Quality Forum's 2010 update of the Safe Practices for Better Healthcare, states healthcare organizations must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care (p. 40).

    IRIS Registry EHR Reporting

    Instructions: 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 know prescriptions, over-the-counter, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medication name, dosage, frequency, and route of administration.

    These are the required elements to be documented at least once a year to meet the measure performance requirements.

    Attestation of documentation of current medications.

    How CMS Scores Your Performance

    • If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
      • Small practices (≤ 15 clinicians) will receive 3 points,
      • Larger practices (> 15 clinicians) will receive 1 point.
    • If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
    • If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
    Decile/Points EHR (including IRIS integration) Registry (No EHR) Claims
    3 86.25 – 91.91 77.08 – 90.22 97.20 – 99.23
    4 91.92 – 94.85 90.23 – 95.97 99.24  - 99.79
    5 94.86 – 96.69 95.98 – 98.60 99.80 – 99.99
    6 96.70 – 97.98 98.61 – 99.69 --
    7 97.99 – 98.87 99.70 – 99.99 --
    8 98.88 – 99.54 -- --
    9 99.55 – 99.95 -- --
    10 >= 99.96 100 100