Understanding and Coding MDS 3.0 Item A2124B: Route of Current Reconciled Medication List Transmission (HIEO to Resident/Family/Caregiver)

Understanding and Coding MDS 3.0 Item A2124B: Route of Current Reconciled Medication List Transmission (HIEO to Resident/Family/Caregiver)

Introduction

Purpose: The accurate transmission of a reconciled medication list is essential to ensuring that residents and their caregivers have the necessary information to manage medications safely after discharge. MDS Item A2124B focuses on whether this list was transmitted via a Health Information Exchange Organization (HIEO) to the resident, their family, or caregiver. Proper documentation and coding of this item reflect the facility's commitment to utilizing advanced health information technology to enhance care transitions.

What is MDS Item A2124B?

Explanation: MDS Item A2124B records the method used to transmit the reconciled medication list to the resident, family, or caregiver at the time of discharge, specifically noting if the transmission occurred through a Health Information Exchange Organization (HIEO). The HIEO serves as a network that allows the sharing of health information across different healthcare settings, ensuring that critical information, such as medication lists, is accessible to patients and their caregivers.

Guidelines for Coding A2124B

Coding Instructions:

1. Step 1: Confirm that the reconciled medication list was transmitted through an HIEO to the intended recipient, whether that is the resident, a family member, or another caregiver.

2. Step 2: Document the successful transmission, ensuring that all necessary steps were taken to securely share the information.

3. Step 3: Code '1' if the transmission occurred via an HIEO. Code '0' if the transmission did not occur through this method.

   • Code 1: Indicates that the reconciled medication list was successfully transmitted via HIEO.
   • Code 0: Indicates that the transmission was not conducted through HIEO.

Example Scenario: Ms. Lee is discharged from the facility after her rehabilitation stay. The facility uses a Health Information Exchange Organization (HIEO) to transmit her reconciled medication list directly to her son, who is her primary caregiver. This ensures that her son has immediate access to her medication information through a secure platform. In this case, MDS Item A2124B should be coded as '1'.

Best Practices for Accurate Coding

Documentation:

• Record the transmission of the medication list via HIEO in the resident’s discharge documentation, including the date of transmission and confirmation that it was received by the intended party.
• Ensure that the HIEO transaction is secure and complies with HIPAA and other relevant privacy regulations.

Communication:

• Confirm with the resident or their caregiver that they have received the medication list through the HIEO and understand the information provided.
• Provide guidance on how to access and use the HIEO for future reference.

Training:

• Train staff on the use of HIEO systems to ensure that they can effectively transmit documents and verify successful transmissions.
• Regularly review and update protocols to ensure compliance with best practices and legal requirements for HIEO use.

Conclusion

Summary: Proper coding of MDS Item A2124B is crucial for documenting that the reconciled medication list was transmitted via an HIEO, ensuring efficient and secure communication during the discharge process. This practice supports continuity of care and helps prevent medication errors after the resident leaves the facility.

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

Reference

• Refer to CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, specifically Chapter 3, Page A-13, for detailed coding instructions on MDS Item A2124B.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item set MDS 3.0 Item A2124B: "Route of Current Reconciled Medication List Transmission (HIEO to Resident/Family/Caregiver)" 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.