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Documentation of Current Medications in the Medical Record

Last updated: September 14, 2018

CMS Measure ID: CMS68v8
Version: 8
NQF Number: 0419
Measure Description:

Percentage of visits for patients aged 18 years and older for which the eligible professionalinfo-icon or eligible clinicianinfo-icon 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.

Initial Patient Population:

All visits occurring during the 12 month measurement period for patients aged 18 years and older.

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

None

Numerator Statement:

Eligible professionalinfo-icon or eligible clinicianinfo-icon attests to documenting, updating or reviewing the patient's 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, dosages, frequency and route of administration

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Medical Reason:

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
Previous Version:
Improvement Notation:

Higher score indicates better quality

Guidance:

This measure is to be reported for every encounter during the measurement period.

Eligible professionalsinfo-icon or eligible cliniciansinfo-icon 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 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 professionalinfo-icon or eligible clinicianinfo-icon 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.

Quality ID: 130
Meaningful Measure: Medication Management

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Added information to rationale section based upon a reference that was added by recommendation of the measure expert work group.

    Measure Section: Rationale

    Source of Change: Expert Work Group Review

  • Removed citation of reference because it is not included in the reference section.

    Measure Section: Rationale

    Source of Change: Expert Work Group Review

  • Added information to rationale section based upon a reference that was added by recommendation of the measure expert work group.

    Measure Section: Reference

    Source of Change: Expert Work Group Review

Logic

  • Added supplemental timing attributes to most datatypes in QDMinfo-icon 5.3 to facilitate accurate retrieval of time related information within CQLinfo-icon logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Medications Encounter Code Set (2.16.840.1.113883.3.600.1.1834): Added 14 CPT codes and deleted 1 CPT code (97532).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced SNOMEDCT single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Medications Encounter Code Set (2.16.840.1.113883.3.600.1.1834): Deleted 1 CPT code (99024). Added 1 HCPCS code (G0515).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources