A2124. Route of Current Reconciled Medication List Transmission to Resident

Step-by-Step Coding Guide for A2124: Route of Current Reconciled Medication List Transmission to Resident

Steps for Assessment and Coding:

1. Identify Transmission Routes:

   • Determine all the methods used to provide the resident’s current reconciled medication list to the intended recipient(s) at discharge.

2. Refer to A2122 Coding Instructions:

   • Use the coding instructions provided for A2122 as a guide for A2124, as they apply to both the transmission of the medication list to subsequent providers and to the resident or their representative.

3. Coding Multiple Transmission Routes:

   • You may select more than one code if multiple methods were used to transmit the medication list.

Common Routes of Transmission:

• Electronic Health Record (EHR): If the facility uses an EHR (also known as EMR) and utilized it to transmit or provide access to the medication list. Direct access to a common EHR system between the discharging and receiving entity is included in this category.

• Health Information Exchange (HIE): When the facility participates in an HIE and used it to electronically exchange the medication list with the recipient.

• Verbal Communication: If the medication list information was verbally conveyed (in-person, telephone, video conferencing) to the recipient.

• Paper-Based Method: When the medication list was transmitted using paper (printout, fax, or eFax).

• Other Methods: If another method not listed above was used (texting, email, CDs).

Examples for Clarity:

• Example 1: If a SNF sends a resident to a hospital and provides a paper printout of the medication list to the ambulance driver, and follows up with a verbal discussion about the medications with the hospital, both paper-based (D) and verbal (C) methods are coded.

• Example 2: When a resident is educated about their medications by a nurse at discharge and also has access to the SNF’s patient portal for their discharge medication list, code Electronic Health Record (A), verbal (C), and paper-based (D) as routes of transmission.

• Example 3: If the SNF participates in an HIE with a local acute care hospital and includes the discharge medication list in a transfer summary document electronically exchanged through the HIE, code Electronic Health Record (A) and Health Information Exchange (B).

Remember:

• Understanding and documenting the facility’s typical transmission methods to each recipient at discharge will aid in accurately coding this item.
• The completeness and accuracy of medication list transmission are critical for resident safety and continuity of care post-discharge​​.

The Step-by-Step Coding Guide for item A2124 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.