eCQM: Documentation of Current Medications in the Medical Record (CMS 68v6)

eCQM:

Documentation of Current Medications in the Medical Record

CMS ID:

CMS 68v6

NQF Number:

N/A

NQS Domain:

Patient Safety

Measure Type:

Process

MIPS High Priority Measure:

Yes

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)

Description:

Percentage of visits for patients aged 18 years and older for which the eligible professional 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.

  • Numerator: Eligible visits from the denominator where the eligible clinician 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.
  • Denominator: All eligible visits (defined as a signed chart note with one of the following encounter types: Office Visit or Home Visit) occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period.
    • Denominator Exclusions: None

    • Denominator Exceptions: 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.

Performance Benchmark for MIPS: 99.76%
For further benchmarks and details on how this measure will be scored within the Quality performance category of MIPS, please click
here.

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to ensure that you gain numerator credit for this measure within the Practice Fusion EHR.

  1. For all visits with patients age 18 and older, review the patient’s medication list and ensure that it is up to date and complete.
  2. In the patient encounter, check the “Documentation of Current Medications” check-box in the Quality of Care section.
  3. Use Step 2 to record that the patient’s current medication list has been documented in the chart at every eligible encounter during the measurement period.

Additional Measure Information

  • CMS defines “current medications” as medications the patient is presently taking, including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication's name, dosage, frequency and administered route.
  • CMS defines “route” as the documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).
  • This measure is to be reported for every encounter during the measurement period. 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.
  • 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.
  • For a patient to be recognized for the denominator exceptions, you may use the suggested workflow detailed in Table 1.

Table 1: Practice Fusion Suggested Workflow for CMS 68v6 Denominator Exception

Denominator Exception Criteria

Practice Fusion Suggested Workflow

Medical or Other reason not done

  • In the Screenings/Interventions/Assessments section of the encounter, search "Documentation of current medications (procedure)" and select the item.

  • Once selected, record the following in the modal window that opens:

    • Status: Not Performed

    • Reason: Medical contraindication, Procedure contraindicated, OR Treatment not tolerated

    • Start Date: If the medical or other reason occurred on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the refusal.

More Information

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  5. eCQM: Documentation of Current Medications in the Medical Record (CMS 68v6)
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