New Medicare star ratings measure: Medication reconciliation post-discharge

We want to let you know about the medical record documentation requirements for a new star ratings measure: Medication reconciliation post-discharge.

About the measure
The measure assesses patients age 18 and older who were discharged from an acute or non-acute inpatient stay between Jan. 1 and Dec. 1 of the measurement year. It looks at patients whose medications were reconciled from the date of discharge through 30 days after discharge (31 days total).

What is medication reconciliation?
Medication reconciliation is a review in which the discharge medications are reconciled with the most recent medication list in the outpatient record. It helps prevent adverse drug reactions and other medication-related issues that can occur after hospitalization. Medication reconciliation should be conducted by a prescribing practitioner, clinical pharmacist or registered nurse.

Medical record documentation requirements
Health care providers must meet certain criteria when documenting evidence of medication reconciliation in Medicare patients’ medical records for the reconciliation to count toward this measure. Documentation in the medical record must include evidence of medication reconciliation and the date it was performed. Any of the following meets documentation criteria:

• A note from the provider that current and discharge medications were reconciled
• The current medication list with a notation that references the discharge medications (for example, no changes in medication since discharge, same medications at discharge, discontinue all discharge medications)
• Current medication list with a notation that the discharge medications were reviewed
• Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service
• Notation that no medications were prescribed or ordered upon discharge

Only documentation in the outpatient chart meets the intent of the measure; an outpatient visit isn’t required. Medication reconciliation can also be done by phone.

Improving quality performance

• Talk to your patients about the importance of maintaining an accurate and up-to-date record of all active medications. Medications can often change between settings and the list of medications can be inaccurate or outdated.
• Encourage your patients to keep a copy of the updated medication list and bring it to all appointments. A comprehensive list of medications should include all prescription medications, herbal supplements, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives and intravenous solutions.
• Explain to your patients that this reconciliation is done to avoid medication errors as they relate to such matters as duplications, omissions, dose, timing and adverse drug interactions.
• Establish a process asking patients to bring their medication bottles, including all over-the-counter preparations, to every health care encounter.
• A computer order entry system should be used when possible. It reduces errors and confusion caused by illegible handwriting.
• The updated hospital medication list and discharge instructions are printed for education and review with the patient before he or she leaves the hospital. Request the medication list to better assist in your review and update of the chart during post-discharge medication reconciliation.
• Always include medication reconciliation in your post-discharge visit note, whether you see your patient during an outpatient visit or you review medications over the phone with your patient.

Using correct procedure codes
CPT codes must be billed on the same date of service.

Note: CPT coding guidelines must be followed. Refer to detailed coding guidelines for the codes *99495 and *99496.