A2122B: Route of Current Reconciled Medication List Transmission: HIEO to Provider, Step-by-Step
Step-by-Step Coding Guide for Item Set A2122B: Route of Current Reconciled Medication List Transmission: HIEO to Provider
1. Review of Medical Records
- Objective: Gather accurate information regarding the transmission of the reconciled medication list via Health Information Exchange Organization (HIEO) to a provider.
- Steps:
- Collect Information: Review the resident’s medical records, including discharge summaries, medication administration records (MARs), and any communication logs.
- Identify Transmission Method: Determine if the reconciled medication list was transmitted via HIEO to the provider.
- Confirm Transmission: Verify documentation that confirms the list was successfully transmitted to the intended provider through the HIEO.
2. Understanding Definitions
- HIEO (Health Information Exchange Organization): An organization that facilitates the electronic sharing of health-related information among healthcare providers.
- Reconciled Medication List: A complete and accurate list of all medications a resident is currently taking, reviewed and updated to resolve any discrepancies.
- Transmission to Provider: The process of sending the reconciled medication list from the facility to the resident’s healthcare provider through HIEO.
3. Coding Instructions
- Steps:
- Identify Transmission via HIEO: Confirm that the reconciled medication list was sent to the provider through HIEO.
- Check Documentation: Ensure there is documentation supporting the transmission via HIEO.
- Code Appropriately: Code A2122B as "1" if the list was transmitted via HIEO to the provider, and "0" if it was not.
4. Coding Tips
- Accurate Identification: Ensure that the transmission method is specifically via HIEO.
- Consistent Terminology: Use consistent terminology in the documentation when referring to HIEO transmission.
- Consult IT Department: If there is any uncertainty about the transmission method, consult with the IT department or relevant staff.
5. Documentation
- Required:
- Transmission Logs: Include logs or records confirming the transmission of the medication list via HIEO.
- Confirmation of Receipt: Documentation from the provider confirming receipt of the medication list.
- Communication Records: Any relevant communication between the facility and the provider regarding the transmission.
6. Common Errors to Avoid
- Misclassification: Ensure that the transmission was specifically through HIEO and not another method.
- Incomplete Documentation: Make sure all relevant details about the transmission are thoroughly documented.
- Assumptions: Do not assume the transmission method without proper documentation.
7. Practical Application
- Example:
- Resident Profile: John, a 65-year-old resident, is being discharged from the facility.
- Steps:
- Review Records: The nurse reviews John’s medical records and communication logs.
- Identify Transmission: It is confirmed that John’s reconciled medication list was transmitted to his primary care provider via HIEO.
- Document and Code: The nurse documents the transmission in the medical records and codes A2122B as "1".
- Outcome: John’s transmission of the reconciled medication list via HIEO is accurately documented and coded, ensuring proper communication and continuity of care.
Please note that the information provided in this guide for MDS 3.0 Item set A2122B 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.
