Step-by-Step Coding Guide for Item Set A2122C: Route of Current Reconciled Medication List Transmission - Verbal to Provider

Step-by-Step Coding Guide for Item Set A2122C: Route of Current Reconciled Medication List Transmission - Verbal to Provider

1. Review of Medical Records

• Objective: Gather accurate information regarding the transmission of the reconciled medication list verbally to the provider.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, nursing notes, discharge summaries, and previous assessments.
  2. Identify Medication Transmission Documentation: Look for documented instances where the reconciled medication list was verbally communicated to a healthcare provider.
  3. Confirm Details: Verify the consistency and accuracy of the verbal transmission documentation through various sources within the medical records.

2. Understanding Definitions

• Reconciled Medication List: A complete and accurate list of all medications the resident is taking, ensuring there are no discrepancies between different care settings.
• Verbal Transmission to Provider: The process of communicating the reconciled medication list to a healthcare provider through spoken words, either in person or over the phone.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm that the reconciled medication list was transmitted verbally to a healthcare provider from the medical records.
  2. Verify Documentation: Ensure the verbal transmission is clearly documented in the resident’s records, including details such as the date, time, and recipient of the information.
  3. Code Appropriately: Code A2122C as "1" if the reconciled medication list was transmitted verbally to the provider, and "0" if it was not.

4. Coding Tips

• Accurate Identification: Ensure the verbal transmission of the reconciled medication list is explicitly mentioned and confirmed by the records.
• Consistent Terminology: Use consistent terminology when documenting and coding the verbal transmission.
• Consult Healthcare Providers: If there is any uncertainty, consult with the attending physician or nurse who transmitted the information for clarification.

5. Documentation

• Required:
  • Physician and Nursing Notes: Document the verbal communication of the reconciled medication list, including the details of the conversation.
  • Discharge Summaries: Include information about the verbal transmission of the reconciled medication list in the discharge summary.
  • Communication Logs: Ensure logs of communication with healthcare providers include details about the verbal transmission of the reconciled medication list.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the verbal transmission through multiple records and consultations.
• Incomplete Documentation: Make sure all relevant notes and logs are included.
• Assumptions: Do not assume the verbal transmission occurred without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Maria, a 70-year-old resident, is being discharged and her reconciled medication list needs to be communicated to her primary care provider.
  • Steps:
    1. Review Records: The nurse reviews Maria’s medical records, including nursing notes and discharge summaries that indicate the reconciled medication list was verbally communicated to her primary care provider.
    2. Identify Transmission: It is confirmed that the reconciled medication list was verbally transmitted to the provider on the day of discharge.
    3. Document and Code: The nurse documents the details of the verbal transmission in Maria’s records and codes A2122C as "1".
  • Outcome: Maria’s verbal transmission of the reconciled medication list to her provider 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 A2122C 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.