Understanding and Coding MDS Item A2122D: Route of Current Reconciled Medication List Transmission - Paper-based to Provider

Understanding and Coding MDS Item A2122D: Route of Current Reconciled Medication List Transmission - Paper-based to Provider

Introduction

Purpose:
MDS Item A2122D, "Route of Current Reconciled Medication List Transmission: Paper-based to Provider," is used to document the method of transmitting a resident’s reconciled medication list to the next care provider upon discharge or transfer from the facility. A reconciled medication list ensures continuity of care by providing accurate, up-to-date medication information, and proper transmission of this list helps prevent medication errors and adverse drug events. This specific item captures when the list is transmitted via paper-based methods to the next provider.

What is MDS Item A2122D?

Explanation:
MDS Item A2122D is part of Section A, which collects administrative and demographic information about the resident. This item documents how the resident’s reconciled medication list is transmitted to the next care provider. A paper-based transmission refers to providing a physical copy of the medication list, which could be delivered by hand, fax, or mail.

The reconciled medication list includes all current medications the resident is taking, including prescribed medications, over-the-counter drugs, and any supplements. It is crucial for ensuring that the receiving provider has accurate information to continue proper medication management.

• Relevance: Transmitting a reconciled medication list is critical for ensuring that healthcare providers involved in the resident’s care have accurate and updated medication information. This is especially important during care transitions to avoid medication discrepancies and prevent adverse drug events.
• Importance: Proper coding of A2122D ensures that the method of transmission is accurately captured in the MDS assessment, facilitating effective communication between healthcare providers.

Guidelines for Coding MDS Item A2122D

Coding Instructions:

1. Confirm the Transmission Method:
   Determine how the resident’s reconciled medication list was sent to the next care provider upon transfer or discharge. If the list was transmitted via paper-based means, such as a printed document, hand-delivered, mailed, or faxed, this should be reflected in A2122D.

2. Answering A2122D:

   • Code 1 (Yes) if the reconciled medication list was transmitted via paper-based means to the next provider (e.g., printed, faxed, or mailed).
   • Code 0 (No) if the list was transmitted through other means (e.g., electronically) or was not transmitted by paper.

3. Documentation Requirements:
   Ensure that the transmission of the reconciled medication list is documented in the resident’s medical record, including the date and how the paper-based document was transmitted (e.g., fax confirmation, mailed copy, or hand-delivered).

4. Verification:
   Confirm that the paper-based transmission took place and that the receiving provider obtained the medication list. This may include a fax receipt or confirmation from the next provider.

Example Scenario:
Upon Mr. Jackson’s discharge from the skilled nursing facility, his reconciled medication list was printed and hand-delivered to his new primary care provider. In this case, code 1 (Yes) for A2122D to reflect that the list was transmitted using a paper-based method.

Best Practices for Accurate Coding

Documentation:
Ensure that all transmissions of the reconciled medication list, including paper-based methods, are well-documented in the resident’s medical record. Include details such as the method used (e.g., hand-delivered or faxed) and any relevant confirmation (e.g., fax receipt).

Communication with Providers:
Coordinate with the receiving provider to confirm receipt of the reconciled medication list. Communication between facilities helps ensure continuity of care and reduces the risk of medication discrepancies.

Training:
Provide training to staff on the importance of transmitting reconciled medication lists during care transitions and how to document these transmissions correctly. Staff should be familiar with different transmission methods and understand the importance of ensuring medication accuracy across care settings.

Conclusion

MDS Item A2122D is essential for documenting when a resident’s reconciled medication list is transmitted to a provider via paper-based methods. Proper coding ensures that medication information is effectively communicated between healthcare providers, supporting continuity of care and preventing medication errors. Accurate documentation, communication, and staff training are key to ensuring successful transitions of care.

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

Reference

For more detailed guidelines on coding MDS Item A2122D, refer to the CMS’s Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Chapter 3, Section A, Page 3-10.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item A2122D: "Route of Current Reconciled Medication List Transmission - Paper-based 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.