Documentation of Current Medications in the Medical Record (2024)
Documentation of Current Medications in the Medical Record (2024)
| eCQMs / NQF #: | CMS68v13 / XXXX |
| Measure: | Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. |
| 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. |
| Denominator: | All visits occurring during the 12-month measurement period for patients aged 18 years and older. |
| 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). |
| Domain: | Patient Safety |
In ChartMaker Clinical:
In order to qualify for this measure, the provider must have seen the patient (age 18 and older) at least one time during the reporting period and have the appropriate information in the chart:
Required Data Elements for the Denominator:
This is captured by adding a procedure with a valid SNOMED, CPT, or HCPCS code using the Procedure widget in a note.
| SNOMED: | |
| Code | Description |
| 10197000 | Psychiatric interview and evaluation (procedure) |
| 108220007 | Evaluation AND/OR management – new patient (procedure) |
| 108221006 | Evaluation AND/OR management – established patient (procedure) |
| 108224003 | Preventive patient evaluation (procedure) |
| 108311000 | Psychiatric procedure, interview AND/OR consultation (procedure) |
| 13607009 | Manual examination of breast (procedure) |
| 14736009 | History and physical examination with evaluation and management of patient (procedure) |
| 163497009 | Obstetric examination (procedure) |
| 165171009 | Initial psychiatric evaluation (procedure) |
| 169762003 | Postnatal visit (regime/therapy) |
| 18091003 | Electronystagmography with vertical electrodes (procedure) |
| 18114009 | Prenatal examination and care of mother (procedure) |
| 183382003 | Psychotherapy – behavioral (regime/therapy) |
| 183383008 | Psychotherapy – cognitive (regime/therapy) |
| 18512000 | Individual psychotherapy (regime/therapy) |
| 185349003 | Encounter for check up (procedure) |
| 185463005 | Visit out of hours (procedure) |
| 185465003 | Weekend visit (procedure) |
| 209099002 | History and physical examination with management of domiciliary or rest home patient (procedure) |
| 210098006 | Domiciliary or rest home patient evaluation and management (procedure) |
| 225967005 | Self-care patient education (procedure) |
| 252592009 | Speech audiometry (procedure) |
| 252624005 | Evoked oto-acoustic emission measurement (procedure) |
| 270427003 | Patient-initiated encounter (procedure) |
| 270430005 | Provider-initiated encounter (procedure) |
| 274803000 | Examination of tympanic membrane (procedure) |
| 277404009 | High frequency tympanometry (procedure) |
| 284015009 | Auditory evoked potentials monitoring (regime/therapy) |
| 308335008 | Patient encounter procedure (procedure) |
| 34651001 | Optokinetic nystagmus test, bidirectional, with recording (procedure) |
| 35025007 | Manual pelvic examination (procedure) |
| 36228007 | Ophthalmic examination and evaluation (procedure) |
| 370803007 | Evaluation of psychosocial impact on plan of care (procedure) |
| 386372009 | Nutrition management (regime/therapy) |
| 390906007 | Follow-up encounter (procedure) |
| 406547006 | Urgent follow-up (procedure) |
| 408983003 | Renal care management (procedure) |
| 410155007 | Occupational therapy assessment (procedure) |
| 410157004 | Occupational therapy management (procedure) |
| 410158009 | Physical therapy assessment (procedure) |
| 410160006 | Physical therapy management (procedure) |
| 410170008 | Nutrition care assessment (procedure) |
| 439708006 | Home visit (procedure) |
| 439952009 | Evaluation of auditory rehabilitation (procedure) |
| 440524004 | Oscillating tracking test with recording (procedure) |
| 46662001 | Examination of breast (procedure) |
| 48423005 | Acoustic reflex testing (procedure) |
| 50357006 | Evaluation and management of patient at home (procedure) |
| 53555003 | Basic comprehensive audiometry testing (procedure) |
| 54290001 | Positional nystagmus test with recording (procedure) |
| 63547008 | Caloric vestibular test with recording (procedure) |
| 66902005 | Ophthalmic examination and evaluation, follow-up (procedure) |
| 698610002 | Education about self management of diabetes (procedure) |
| 78318003 | History and physical examination, annual for health maintenance (procedure) |
| 83607001 | Gynecologic examination (procedure) |
| 8411005 | Interactive individual medical psychotherapy (regime/therapy) |
| 86013001 | Periodic reevaluation and management of healthy individual (procedure) |
| 870422002 | Assessment of self management of diabetes mellitus (procedure) |
| 90526000 | Initial evaluation and management of healthy individual (procedure) |
| CPT: | |
| Code | Description |
| 59400 | Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care |
| 59510 | Routine obstetric care including antepartum care, cesarean delivery, and postpartum care |
| 59610 | Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery |
| 59618 | Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery |
| 90791 | Psychiatric diagnostic evaluation |
| 90792 | Psychiatric diagnostic evaluation with medical services |
| 90832 | Psychotherapy, 30 minutes with patient |
| 90834 | Psychotherapy, 45 minutes with patient |
| 90837 | Psychotherapy, 60 minutes with patient |
| 90839 | Psychotherapy for crisis; first 60 minutes |
| 91573000 | Tympanometry testing (procedure) |
| 92002 | Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient |
| 92004 | Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits |
| 92012 | Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient |
| 92014 | Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals |
| 92526 | Treatment of swallowing dysfunction and/or oral function for feeding |
| 92537 | Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) |
| 92538 | Caloric vestibular test with recording, bilateral; monothermal (ie, one irrigation in each ear for a total of two irrigations) |
| 92540 | Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording |
| 92541 | Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording |
| 92542 | Positional nystagmus test, minimum of 4 positions, with recording |
| 92544 | Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording |
| 92545 | Oscillating tracking test, with recording |
| 92547 | Use of vertical electrodes (List separately in addition to code for primary procedure) |
| 92548 | Computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (ie, eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report |
| 92549 | Computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (ie, eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report; with motor control test (MCT) and adaptation test (ADT) |
| 92550 | Tympanometry and reflex threshold measurements |
| 92557 | Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) |
| 92567 | Tympanometry (impedance testing) |
| 92568 | Acoustic reflex testing, threshold |
| 92570 | Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing |
| 92588 | Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report |
| 92626 | Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour |
| 92650 | Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis |
| 92651 | Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report |
| 92652 | Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report |
| 92653 | Auditory evoked potentials; neurodiagnostic, with interpretation and report |
| 96116 | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour |
| 96156 | Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making) |
| 96158 | Health behavior intervention, individual, face-to-face; initial 30 minutes |
| 97129 | Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes |
| 97161 | Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family. |
| 97162 | Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 97163 | Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
| 97164 | Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. |
| 97165 | Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 97166 | Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
| 97167 | Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
| 97168 | Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 97802 | Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes |
| 97803 | Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes |
| 97804 | Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes |
| 98960 | Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient |
| 98961 | Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients |
| 98962 | Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients |
| 99202 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter. |
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. |
| 99211 | Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. |
| 99221 | Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. |
| 99222 | Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. |
| 99223 | Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. |
| 99236 | Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded. |
| 99281 | Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional |
| 99282 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making |
| 99283 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making |
| 99284 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making |
| 99285 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making |
| 99304 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. |
| 99305 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. |
| 99306 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. |
| 99307 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. |
| 99308 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. |
| 99309 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
| 99310 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. |
| 99315 | Nursing facility discharge management; 30 minutes or less total time on the date of the encounter |
| 99316 | Nursing facility discharge management; more than 30 minutes total time on the date of the encounter |
| 99341 | Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. |
| 99342 | Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
| 99344 | Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. |
| 99345 | Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. |
| 99347 | Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. |
| 99348 | Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
| 99349 | Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. |
| 99350 | Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. |
| 99385 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years |
| 99386 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years |
| 99387 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older |
| 99395 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years |
| 99396 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years |
| 99397 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older |
| 99424 | Principal care management services, for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death, the condition requires development, monitoring, or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities, ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. |
| 99491 | Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. |
| 99495 | Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge At least moderate level of medical decision making during the service period Face-to-face visit, within 14 calendar days of discharge |
| 99496 | Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge High level of medical decision making during the service period Face-to-face visit, within 7 calendar days of discharge |
| HCPCS: | |
| Code | Description |
| G0101 | Cervical or vaginal cancer screening; pelvic and clinical breast examination |
| G0108 | Diabetes outpatient self-management training services, individual, per 30 minutes |
| G0270 | Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes |
| G0402 | Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment |
| G0438 | Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit |
| G0439 | Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit |
Denominator Exception:
There is no exclusion for this measure. However, there is a denominator exception when a 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. In order to meet the requirements for this exception, the appropriate information must be documented in the chart:
This is captured by checking the Current Medications Not Documented For Medical/Other Reason menu item via the Medication button in a note.
Or by attaching one of the following applicable SNOMED codes to a procedure code.
| SNOMED: | |
| Code | Description |
| 183932001 | Procedure contraindicated (situation) |
| 183964008 | Treatment not indicated (situation) |
| 183966005 | Drug treatment not indicated (situation) |
| 266721009 | Absent response to treatment (situation) |
| 269191009 | Late effect of medical and surgical care complication (disorder) |
| 31438003 | Drug resistance (disorder) |
| 35688006 | Complication of medical care (disorder) |
| 397745006 | Medical contraindication (finding) |
| 407563006 | Treatment not tolerated (situation) |
| 410534003 | Not indicated (qualifier value) |
| 410536001 | Contraindicated (qualifier value) |
| 416098002 | Allergy to drug (finding) |
| 428119001 | Procedure not indicated (situation) |
| 59037007 | Intolerance to drug (finding) |
| 62014003 | Adverse reaction caused by drug (disorder) |
| 79899007 | Drug interaction (finding) |
Required Data Element for the Numerator:
This is captured by checking the Current Medications Documented menu item via the Medication button in a note.
NOTE: This menu item will automatically be checked for the user if the previously entered medication encounter note had current medications documented checked.
ADDITIONAL INFORMATION:
- This measure is to be reported for every encounter during the measurement period. This measure is not based on unique patients, therefore if a patient meeting the measure criteria was seen more than once during the reporting period, that patient would be counted in the numerator/denominator more than once.
- Eligible professionals reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.
- This measure should also be reported if the eligible professional documented the patient is not currently taking any medications.
- To meet the numerator, the eligible professional 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. Route of administration should be documented on how the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).
- The “Current Medications Documented” choice is defaulted to being checked. If you can not attest to the information in the bullet point above, it should be unchecked.
- When “Current Medications Documented” is unchecked, the system will automatically apply a reason code for the procedure not done (Medical Reason).
- The only data used to determine the denominator is data from the ChartMaker Clinical Module. If a patient encounter was not entered into the ChartMaker Clinical Module, that encounter is not included in the denominator for the statistical calculations on the Meaningful Use Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.