A2124D: Route of Current Reconciled Medication List Transmission: Paper-based to Resident/Family/Caregiver, Step-by-Step

Step-by-Step Coding Guide for Item Set A2124D: Route of Current Reconciled Medication List Transmission: Paper-based to Resident/Family/Caregiver

1. Review of Medical Records

• Objective: To confirm the method used for transmitting the current reconciled medication list to the resident, family, or caregiver in a paper-based format.
• Process:
  • Examine the medication management and reconciliation records to identify the format in which medication lists were most recently updated and shared.
  • Review communications logs or notes from the nursing staff or care coordinators that indicate how medication information was provided to the resident or their representatives.
  • Consult with the pharmacy department or staff responsible for preparing and distributing medication lists to verify the method of dissemination.

2. Understanding Definitions

• Current Reconciled Medication List: A comprehensive list of all medications a resident is currently taking, verified for accuracy at the point of transition or change in care levels.
• Paper-based Transmission: The process of providing a physical, printed copy of the medication list to the resident, family, or caregiver.

3. Coding Instructions

• Code A2124D:
  • 1: If the current reconciled medication list was transmitted to the resident, family, or caregiver via paper.
  • 0: If the list was not transmitted via paper.
• Example: If upon discharge, the nursing staff provides a printed copy of the reconciled medication list to the resident’s daughter, code A2124D as '1'.

4. Coding Tips

• Ensure that the transmission method aligns with what is documented in the care transition or discharge planning records.
• Verify the recipient of the medication list to ensure it matches the coding requirement (resident, family, or caregiver).

5. Documentation

• Required Documentation:
  • Documentation in the resident’s health record indicating that a paper copy of the medication list was provided, including the date and to whom it was given.
  • Copies of signed receipts or acknowledgments by the recipient, if available, confirming receipt of the medication list.
• Documentation should be clear and detailed to verify compliance with medication reconciliation and information transmission standards.

6. Common Errors to Avoid

• Assuming electronic transmission or verbal communication meets the criteria for paper-based transmission.
• Failing to document the method of transmission in the resident's medical records.
• Overlooking the importance of confirming the recipient’s receipt of the medication list.

7. Practical Application

• Scenario: A resident is transitioning back home under the care of his son after a short rehabilitation stay post-surgery. The care coordinator completes a medication reconciliation and prepares a detailed, printed medication list, which includes instructions for each medication. The list is reviewed with the son, who receives the document during a discharge meeting. The event is documented in the discharge summary, including the son’s signature acknowledging receipt. For MDS coding, based on this documentation, A2124D is accurately coded as '1', indicating that the medication list was indeed transmitted via a paper-based route to the family member.

Please note that the information provided in this guide for MDS 3.0 Item set A2124D 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.