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Documentation of Current Medications in the Medical Record

Compare Versions of: "Documentation of Current Medications in the Medical Record"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Compare 2025 version to

Table Options
Measure Information 2025 Performance Period
Title Documentation of Current Medications in the Medical Record
CMS eCQM ID CMS68v14
CBE ID* Not Applicable
MIPS Quality ID 130
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Description

Percentage of visits 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 Scoring Proportion measure
Measure Type Process
Stratification

None

Risk Adjustment

None

Rationale

According to the National Center for Health Statistics, during the years of 2013-2016, 48.4% of patients (both male and female) were prescribed at least one prescription medication with 12.6% taking 5 or more medications. Additionally, 89.8% of patients (both male and female) aged 65...

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Clinical Recommendation Statement

The Joint Commission's 2023 Ambulatory Health Care National Patient Safety Goals guide clinicians to maintain and communicate accurate patient medication information (2023). Specifically, the section NPSG.03.06.01 "Maintain and communicate accurate patient medication information" states...

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Improvement Notation

Higher score indicates better quality

Definition

Current Medications:

Medications the patient is presently taking including all prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, and cannabis/cannabidiol (CBD) products with each medication's name, dosage, frequency and administered...

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Guidance

This eCQM is an episode-based measure. An episode is defined as each eligible encounter during the measurement period. This measure is to be reported for every eligible encounter during the measurement period.

Eligible clinicians reporting this measure may document medication information...

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Initial Population

All visits occurring during the 12-month measurement period

Denominator

Equals Initial Population

Denominator Exclusions

None

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

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)

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Telehealth Eligible Yes
Next Version No Version Available
Previous Version

Header

  • Updated the eCQM version number.

    Measure Section:

    eCQM Version Number

    Source of Change:

    Annual Update

  • Changed all references from NQF to CBE to identify the consensus-based entity role.

    Measure Section:

    CBE Number

    Source of Change:

    Annual Update

  • Removed Denominator age requirement. Changed Initial Population age criteria from 18 and older to all ages based on expert input that medications should be documented or reviewed for patients of all ages.

    Measure Section:

    Description

    Source of Change:

    Expert Work Group Review

  • Updated copyright.

    Measure Section:

    Copyright

    Source of Change:

    Annual Update

  • Updated Guidance to reflect change in Numerator timing to allow for the attestation of medication review to be completed during the day of the encounter to allow for different clinical workflows.

    Measure Section:

    Guidance

    Source of Change:

    Measure Lead

  • Removed Denominator age requirement. Changed Initial Population age criteria from 18 and older to all ages based on expert input that medications should be documented or reviewed for patients of all ages.

    Measure Section:

    Initial Population

    Source of Change:

    Expert Work Group Review

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section:

    Multiple Sections

    Source of Change:

    Annual Update

  • Updated references and measure header to reflect current evidence and new or updated literature.

    Measure Section:

    Multiple Sections

    Source of Change:

    Measure Lead

Logic

  • Removed age requirement that patients be 18 years or older at the start of the measurement period. Changed Initial Population from 18 and older to all ages based on expert input that medications should be documented or reviewed for patients of all ages.

    Measure Section:

    Initial Population

    Source of Change:

    Expert Work Group Review

  • Updated Numerator timing to allow for the attestation of medication review to be completed during the day of the encounter to allow for different clinical workflows.

    Measure Section:

    Numerator

    Source of Change:

    Measure Lead

  • Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.

    Measure Section:

    Definitions

    Source of Change:

    Standards/Technical Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    Measure Section:

    Definitions

    Source of Change:

    Annual Update

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    Measure Section:

    Functions

    Source of Change:

    Annual Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Encounter to Document Medications (2.16.840.1.113883.3.600.1.1834): Added 1 CPT code (92622) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (99211) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section:

    Terminology

    Source of Change:

    Measure Lead

  • Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.

    Measure Section:

    Terminology

    Source of Change:

    Annual Update

Last Updated: Aug 01, 2024