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Documentation of Current Medications in the Medical Record

General eCQM Information

CMS Measure ID CMS68v10
NQF Number 0419e
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

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

Equals Initial Population

Denominator Exclusions

None

Numerator Statement

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

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)

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Domain Patient Safety
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality

Guidance

This eCQM is an episode-based measure. This measure is to be reported for every encounter during the measurement period.

Eligible professionals or eligible clinicians reporting 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.

This measure should also be reported if the eligible professional or eligible clinician documented the patient is not currently taking any medications.

By reporting 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.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Quality ID 130
Meaningful Measure Medication Management
Telehealth Eligible Yes
Next Version
Previous Version

Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated the measure developer field.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Removed language that defines all known medications from the description field.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards Update

  • Updated rationale citations to align with American Psychological Association (APA) formatting.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement citation to reflect updated guideline year.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references to align with APA formatting.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated reference to reflect updated guideline year.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Revised guidance language to capture specificity regarding all known medications that was previously included in the description and numerator fields.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Removed language that defines all known medications from the numerator field.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Revised denominator exception language to follow a similar format as other eCQMs.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

Logic

  • Added the 'Intervention, Performed' QDM category and datatype to allow for an alternate method for capturing the clinical action of documenting the medications.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (Jira): CQM-3347

  • Added the 'Intervention, Not Performed' QDM category and datatype to allow for an alternate method for capturing that the clinical action of documenting the medications was not done.

    Measure Section: Denominator Exceptions

    Source of Change: ONC Project Tracking System (Jira): CQM-3347

  • Revised Clinical Quality Language (CQL) definition construction to reduce the overall complexity of the measure logic without changing the intent and/or application of data element. These revisions were intended to make the definition logic less complex, easier to understand, and more meaningful.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated CQL definition names and aliases used to more closely align with clinical concept intent or create consistency of naming across measures.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards 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 (2.16.840.1.113883.3.600.1.1834): Renamed to Encounter to Document Medications to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Encounter to Document Medications (2.16.840.1.113883.3.600.1.1834): Deleted 1 HCPCS code (G0515) based on terminology update. Added 3 CPT codes (96156, 96158, 97129) and deleted 4 CPT codes (96150, 96151, 96152, 97127) based on terminology update. Deleted 1 SNOMED CT code (32537008) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Medical or Other Reason Not Done (2.16.840.1.113883.3.600.1.1502) with grouping value set Medical Reason (2.16.840.1.113883.3.526.3.1007) for harmonization purposes, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: May 05, 2021