A2122E: Route of Current Reconciled Medication List Transmission - Other Methods to Provider, Step-by-Step

Step-by-Step Coding Guide for Item Set A2122E: Route of Current Reconciled Medication List Transmission - Other Methods to Provider

Step-by-Step Coding Guide for Item Set A2122E: Route of Current Reconciled Medication List Transmission - Other Methods to Provider

1. Review of Medical Records

• Objective: To identify if the current reconciled medication list was transmitted to the subsequent provider using methods other than electronic health records (EHR), health information exchange organization (HIEO), verbal, or paper-based methods.
• Process:
  • Discharge Summaries: Review the discharge summaries to check the methods used for transmitting the medication list.
  • Progress Notes: Check the nursing and physician progress notes for documentation of the transmission method.
  • Communication Logs: Review logs of any communication with the subsequent provider to identify the method used for transmission.
  • Care Coordination Notes: Look for notes from care coordinators detailing how the medication list was transmitted.

2. Understanding Definitions

• Other Methods to Provider: This refers to any method of transmitting the reconciled medication list that is not covered by the predefined categories (EHR, HIEO, verbal, paper-based). Examples could include secure messaging systems, mobile health applications, or other electronic means not classified under EHR or HIEO.

3. Coding Instructions

• Code A2122E:
  • 0: No, the medication list was not transmitted using other methods.
  • 1: Yes, the medication list was transmitted using other methods.
• Example: If the medication list was sent via a secure mobile health application, code A2122E as '1'.

4. Coding Tips

• Clear Documentation: Ensure the method of transmission is clearly documented in the resident’s records.
• Verification: Confirm with the care team that the method used does not fall under EHR, HIEO, verbal, or paper-based categories.

5. Documentation

• Required Documentation:
  • Discharge Summaries: Include details of how the medication list was transmitted.
  • Communication Logs: Records showing the use of other methods.
  • Care Coordination Notes: Detailed notes confirming the method used.
• Example: "On 05/10/2024, the reconciled medication list was transmitted to the subsequent provider using a secure mobile health application, as documented in the discharge summary and communication log."

6. Common Errors to Avoid

• Incorrect Classification: Do not classify methods under 'Other' if they fit into the predefined categories.
• Incomplete Documentation: Ensure that the specific method used is thoroughly documented and justified.
• Assumptions: Avoid assuming the method used without proper verification and documentation.

7. Practical Application

• Scenario: A resident’s reconciled medication list was transmitted to their subsequent provider using a secure messaging system that does not fall under EHR, HIEO, verbal, or paper-based methods. This method is documented in the discharge summary and confirmed by the care coordinator. Thus, A2122E is coded as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set A2122E 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.