Understanding and Coding MDS 3.0 Item A2123: Provision of Current Reconciled Medication List (To Resident)

Understanding and Coding MDS 3.0 Item A2123: Provision of Current Reconciled Medication List (To Resident)

Introduction

Purpose: The provision of a current reconciled medication list to residents upon discharge is crucial for ensuring continuity of care and minimizing the risk of medication errors. Accurate coding of MDS Item A2123 is essential for documenting that this important step has been completed, reflecting a facility's commitment to safe patient transitions.

What is MDS Item A2123?

Explanation: MDS Item A2123 pertains to whether a current reconciled medication list was provided to the resident at the time of discharge. This item is vital in ensuring that residents and their caregivers are aware of all medications they should continue or discontinue after leaving the facility. Proper communication of this information can prevent adverse drug events and supports the ongoing management of the resident’s health.

Guidelines for Coding A2123

Coding Instructions:

1. Step 1: Review the resident's discharge documentation to confirm if a current reconciled medication list was provided.

2. Step 2: Determine the accuracy of the reconciliation by cross-referencing it with the resident's final medication orders.

3. Step 3: Code '1' if the reconciled medication list was provided to the resident upon discharge. Code '0' if it was not provided.

   • Code 1: Indicates that the resident received a current reconciled medication list at the time of discharge.
   • Code 0: Indicates that the resident did not receive this information.

Example Scenario: A resident, Mrs. Smith, is being discharged from the facility after a short-term rehabilitation stay. The facility’s pharmacist reconciles her medications, ensuring that all prescriptions are accurate and updated. The reconciled medication list is then provided to Mrs. Smith and her family during the discharge process. In this case, MDS Item A2123 should be coded as '1'.

Best Practices for Accurate Coding

Documentation:

• Ensure the reconciled medication list is clearly documented in the resident's discharge summary.
• The list should include all medications that the resident is to take at home, along with clear instructions for each.

Communication:

• Engage with the interdisciplinary team, including nursing, pharmacy, and social work, to ensure that the reconciled medication list is accurate and thoroughly explained to the resident.
• Encourage residents or their caregivers to ask questions and confirm their understanding of the medication instructions.

Training:

• Provide ongoing education to staff on the importance of medication reconciliation and accurate documentation.
• Conduct regular audits to ensure compliance with the provision of reconciled medication lists upon discharge.

Conclusion

Summary: Accurate coding of MDS Item A2123 is essential to ensuring that residents are safely transitioned from the facility to their next care setting or home. Providing a current reconciled medication list can significantly reduce the risk of medication errors, thereby improving the quality of care.

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-12, for detailed coding instructions on MDS Item A2123.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item set MDS 3.0 Item A2123: "Provision of Current Reconciled Medication List (To Resident)" 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.