Step-by-Step Coding Guide for Item Set A2122A: Route of Current Reconciled Medication List Transmission - EHR to Provider

1. Review of Medical Records

• Objective: Ensure the accurate transmission of the current reconciled medication list from the electronic health record (EHR) to the provider.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, focusing on the reconciliation of medication lists and transmission logs.
  2. Identify Transmission Records: Look for documentation that the reconciled medication list was transmitted to the provider via the EHR.
  3. Confirm Details: Verify the consistency and accuracy of the transmission documentation within the medical records.

2. Understanding Definitions

• Route of Transmission - EHR to Provider: This involves sending the current reconciled medication list from the facility’s electronic health record system to the resident’s provider electronically.
• Key Points:
  • Reconciled Medication List: A comprehensive list of medications that the resident is currently taking, reviewed and confirmed for accuracy.
  • EHR Transmission: The process of sending information electronically via the facility’s health record system to the provider.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm that the reconciled medication list was transmitted from the EHR to the provider.
  2. Verify Documentation: Ensure the transmission is clearly documented, including the date and method of transmission.
  3. Code Appropriately: Enter the code for the route of transmission as EHR to provider in item set A2122A:
     • 1: Yes, the reconciled medication list was transmitted via EHR to the provider.
     • 0: No, the reconciled medication list was not transmitted via EHR to the provider.

4. Coding Tips

• Accurate Identification: Ensure the transmission of the reconciled medication list via EHR is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the transmission route.
• Confirm EHR Capabilities: Ensure the facility’s EHR system has the capability to electronically transmit the reconciled medication list to the provider.

5. Documentation

• Required:
  • Transmission Logs: Logs from the EHR system documenting the transmission of the reconciled medication list to the provider.
  • Physician Notes: Documentation from physicians confirming receipt of the reconciled medication list.
  • Nursing Notes: Notes from nursing staff detailing the reconciliation process and transmission confirmation.
  • EHR Records: Screenshots or records from the EHR system showing the successful transmission to the provider.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the EHR transmission through multiple records and logs.
• Incomplete Documentation: Make sure all relevant transmission logs, physician notes, and nursing notes are included to support the EHR transmission.
• Assumptions: Do not assume the reconciled medication list was transmitted via EHR without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: David, an 80-year-old resident, had his medication list reconciled during his recent assessment.
  • Steps:
    1. Review Records: The nurse reviews David’s medical records, noting the reconciliation of his medication list.
    2. Identify Transmission: The nurse confirms that the reconciled medication list was transmitted via the EHR to David’s primary care provider.
    3. Document and Code: The nurse documents the transmission details in David’s records and codes A2122A as "1".
  • Outcome: David’s reconciled medication list transmission via EHR is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set A2122A was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.