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Documentation of Current Medications in the Medical Record

General eCQM Information

CMS Measure ID CMS68v11
NQF Number Not Applicable
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 Type Process
Improvement Notation

Higher score indicates better quality

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 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.

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 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.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • ​Removed NQF number and notation of endorsement from measure header because this measure is no longer endorsed by NQF.

    Measure Section: NQF Number

    Source of Change: Measure Lead

  • Updated Measure Developer.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • ​Removed NQF number and notation of endorsement from measure header because this measure is no longer endorsed by NQF.

    Measure Section: Endorsed By

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Annual Update

  • ​Updated rationale to incorporate current literature and statistics.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement to align with The Joint Commission's 2020 Ambulatory Health Care National Patient Safety Goals guide.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Relocated the provider attestation statement in the guidance section to improve readability.

    Measure Section: Guidance

    Source of Change: Annual Update

  • Added clarifying language to guidance section of episode-based measures to define the episode.

    Measure Section: Guidance

    Source of Change: Annual Update

  • Removed extraneous comma in Supplemental Data Elements field.

    Measure Section: Supplemental Data Elements

    Source of Change: Annual Update

Logic

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Definitions

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    Measure Section: Functions

    Source of Change: Standards Update

  • Updated the names of Clinical Quality Language (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

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 6 CPT codes (99211, 92549, 92650, 92651, 92652, 92653) based on terminology update. Deleted 2 CPT codes (92585, 99201) based on terminology update. Added 7 SNOMED CT codes (183382003, 163497009, 169762003, 18114009, 183383008, 698610002, 870422002) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (273643004, 385973000, 405096004) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021