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Documentation of Current Medications in the Medical Record

CBE ID
0419e
1.4 Project
Endorsed
Endorsement Status
1.1 New or Maintenance
E&M Cycle
Is Under Review
No
1.3 Measure Description

For both the 2018 claims and registry specifications AND the 2019 performance period eMeasure (v8) the measure description is as follows:
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. 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.

        • 1.14 Numerator

          Numerator statements for both the 2018 claims and registry specifications and the 2019 performance period eMeasure (v8) is as follows:
          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. This list must include ALL prescriptions, over-the counters, herbals, vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency, and route of administration.

        • 1.15 Denominator

          Denominator statement for the 2018 claims and registry specifications is as follows: “All visits for patients aged 18 years and older.”

          Denominator statement for the 2019 performance period eMeasure (v8) is “Equals Initial Population”. Initial Population is defined as: “All visits occurring during the 12 month measurement period for patients aged 18 years and older.”

        • Exclusions

          Denominator exception for the 2018 claims and registry specifications is as follows:
          A patient is not eligible if the following reason is documented: 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 on the date of the encounter

          Denominator exception for the 2019 performance period eMeasure (v8) is as follows:
          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

        • Most Recent Endorsement Activity
          Measure Retired and Endorsement Removed Patient Safety Spring Cycle 2020
          Initial Endorsement
          Last Updated
          Removal Date
        • Steward Organization Email
          Steward Organization Copyright

          Claims and Registry Copyright Statement:
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          Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the data contained in this file is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file.
          Any use of CPT beyond the terms of the license Agreement that you agreed to for personal non-commercial use, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT, creating any modified or derivative work of CPT, or making any commercial use of CPT, requires a separate license from the AMA. Applications for license are available at the AMA Web site, www.ama-assn.org/go/cpt

          E Measure Copyright Statement:
          Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications.

          CPT (R) contained in the Measure specifications is copyright 2007-2014 American Medical Association.

          LOINC (R) copyright 2004-2014 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2013 [2013-09] International Health Terminology Standards Development Organization. All Rights Reserved.