A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider

Step-by-Step Coding Guide for Item Set A2122: Route of Current Reconciled Medication List Transmission to Subsequent Provider

This guide provides detailed instructions for accurately coding and documenting the method used to transmit a reconciled medication list to a subsequent provider upon a resident's transfer, as specified in item A2122.

1. Review of Medical Records

• Objective: Identify the transmission method used for the current reconciled medication list.
• Key Points:
  • Examine discharge or transfer documentation to determine how the medication list was communicated to the next care provider.
  • Look for notes or documentation from staff responsible for coordinating care transitions, which may specify the transmission route.

2. Understanding Definitions

• Objective: Clarify the transmission methods for medication lists.
• Key Points:
  • Transmission Route: The method used to send the reconciled medication list to another healthcare provider. Common routes include electronic transmission (e.g., email, electronic health record system), fax, mail, or hand delivery.

3. Coding Instructions

• Objective: Guide on selecting the appropriate code for the transmission route.
• Key Points:
  • Code for electronic transmission if the list was sent through email, EHR, or another digital method.
  • Code for fax if the list was sent via a facsimile machine.
  • Code for mail if the list was sent through postal or courier service.
  • Code for hand delivery if the list was given directly to the provider or a representative.

4. Coding Tips

• Verify the transmission method directly with the staff member who coordinated the transfer or with the receiving facility if unclear.
• Familiarize yourself with the facility's standard practices for medication list transmission to correctly interpret documentation.

5. Documentation

• Objective: Maintain accurate records regarding the transmission of medication lists.
• Key Points:
  • Document in the resident’s transfer summary or discharge paperwork the method used to transmit the medication list, including the date and time of transmission.
  • Keep a copy of the transmitted medication list in the resident's file, along with a note indicating how and when it was sent to the subsequent provider.

6. Common Errors to Avoid

• Failing to document the transmission route in the resident’s medical record, leading to potential confusion or miscommunication.
• Incorrectly coding the transmission method due to assumptions rather than verification of the actual method used.

7. Practical Application

• Scenario: Mrs. Smith is being transferred from the nursing facility to a specialized rehabilitation center. The RN Coordinator reconciles her medication list as part of the discharge process and transmits it electronically via the facility's EHR system to the receiving center. The coordinator notes in Mrs. Smith’s discharge summary the electronic transmission of the medication list, including the date and time sent. This action is coded appropriately in A2122 as electronic transmission.

The Step-by-Step Coding Guide for item A2122 in MDS 3.0 Section A is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.