A2122D: Route of Current Reconciled Medication List Transmission - "Paper-based to Provider",step-by-step

Step-by-Step Coding Guide for A2122D: Route of Current Reconciled Medication List Transmission – "Paper-based to Provider"

1. Review of Medical Records

Objective: Determine if the current reconciled medication list was transmitted to the subsequent provider using a paper-based method, such as a printout, fax, or eFax.

Actions:

• Review the discharge documentation to identify the method used to transmit the reconciled medication list to the provider.
• Verify if a paper-based method (printout or fax) was utilized, either directly handed over or sent electronically through a fax machine or eFax service.

2. Understanding Definitions

A2122D: Paper-based transmission refers to the use of printed or faxed documents to send the reconciled medication list to the subsequent provider. This could include sending a paper copy with the resident or faxing it to the receiving provider.

Example Scenario:

• Resident A: The facility sends a printout of the reconciled medication list with the resident to their new provider. This would be coded as A2122D: Paper-based.

3. Coding Instructions

Step-by-Step:

• Step 1: Check if the medication list was transmitted using a paper-based method, such as a printed list or fax.
• Step 2: If a paper-based transmission was used, select A2122D.
• Step 3: Ensure the method is properly documented in the medical record.

4. Coding Tips

• Paper-Based Transmission: Includes any method where the reconciled medication list is printed or faxed, regardless of whether it was faxed through a machine or eFax.
• Document Accuracy: Ensure that the documentation reflects the method used to transmit the reconciled medication list accurately.

5. Documentation

Objective: Record the transmission method of the reconciled medication list clearly to ensure continuity of care for the resident.

Actions:

• Document the paper-based method used, such as a printout provided at discharge or a fax sent to the receiving provider.
• Verify that the method is listed in the resident's discharge paperwork for continuity of care.

6. Common Errors to Avoid

• Confusing Methods: Do not confuse electronic transmissions like EHR access with paper-based methods such as printouts or faxes.
• Incomplete Documentation: Ensure that the paper-based method is clearly documented to avoid discrepancies in transmission records.

7. Practical Application

Example 1:
A resident is discharged to a nursing facility, and the reconciled medication list is faxed to the new facility. This would be coded as A2122D: Paper-based.

Example 2:
A printout of the resident's medication list is provided to the ambulance staff transporting the resident to another provider. This would also be coded as A2122D.

Please note that the information provided in this guide for MDS 3.0 Item set A2122D 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.