Understanding and Coding MDS 3.0 Item A2121: "Provision of Current Reconciled Medication List (To Provider)"

Understanding and Coding MDS 3.0 Item A2121: "Provision of Current Reconciled Medication List (To Provider)"

Introduction

Purpose:

MDS 3.0 Item A2121, "Provision of Current Reconciled Medication List (To Provider)," is an important aspect of ensuring continuity of care when a resident is discharged from a long-term care facility. Accurate documentation of this item confirms that a current and reconciled medication list has been provided to the next care provider, which is crucial for preventing medication errors and ensuring that the resident continues to receive appropriate medications without interruption.

What is MDS Item A2121?

Explanation:

MDS Item A2121 records whether a current, reconciled medication list was provided to the next care provider when a resident is discharged from the facility. A reconciled medication list is an up-to-date document that accurately reflects all medications the resident was taking at the time of discharge, including prescriptions, over-the-counter drugs, vitamins, and supplements. This list is essential for ensuring that the resident’s medication regimen is continued appropriately after discharge, whether they are going home, transferring to another facility, or entering a different care setting.

Properly reconciling and transferring this medication list helps to prevent medication errors such as omissions, duplications, dosing errors, or drug interactions, which are common risks during care transitions.

Guidelines for Coding A2121

Coding Instructions:

1. Verify Provision of Medication List:

   • Confirm whether a reconciled medication list was provided to the next care provider at the time of discharge. This should include verification from the receiving provider or documentation that the list was sent.

2. Response Coding:

   • Code 0 if a reconciled medication list was not provided to the next care provider.
   • Code 1 if a reconciled medication list was provided to the next care provider.

3. Documentation:

   • Maintain thorough documentation of the provision of the reconciled medication list, including details such as the date it was sent, the method of transmission (e.g., electronic, fax, hand-delivered), and confirmation of receipt by the next care provider. This documentation is essential for compliance with regulatory requirements and for ensuring a smooth care transition.

Example Scenario:

Ms. Johnson is being discharged from the long-term care facility to her primary care physician’s care. A reconciled medication list, including all current prescriptions and over-the-counter medications, is sent electronically to her physician before discharge. For MDS Item A2121, this would be coded as 1 to indicate that the list was provided.

Best Practices for Accurate Coding

Documentation:

• Ensure that the reconciled medication list is up-to-date and accurately reflects all medications the resident is taking. Include details of any recent changes to the medication regimen. Document the process of providing this list to the next care provider, including confirmation of receipt.

Communication:

• Foster clear communication between the care team, the resident, their family, and the next care provider to ensure that everyone is aware of the resident’s current medications. This helps to avoid confusion or errors after discharge.

Training:

• Train staff on the importance of medication reconciliation and the process of creating and transferring a reconciled medication list. Emphasize the critical role this plays in preventing medication errors and ensuring safe transitions of care.

Conclusion

Summary:

Accurately coding MDS Item A2121 is essential for documenting that a current reconciled medication list has been provided to the next care provider at the time of discharge. This practice is crucial for ensuring continuity of care, preventing medication errors, and supporting the resident’s health and safety after discharge.

Click here to see a detailed the Step-by-step on how to complete this item set.

Reference

This information is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Page 2-14.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item A2121: "Provision of Current Reconciled Medication List (To Provider)" was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.