CMS 68 - Documentation of Current Medications in the Medical Record

Overview

CMS68v9 (2020)
CMS68v10 (2021)
CMS68v11 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS68v11	–	–	130

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description	Percentage of visits for patients aged 18 years and older for which the eligible professional or attests to documenting a list of current medications using all immediate resources available on the date of the encounter
Initial Patient Population	All visits occurring during the 12-month measurement period for patients aged 18 years and older
Denominator	Equals Initial Population
Denominator Exclusions	–
Numerator	Eligible professional or attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter
Numerator Exclusions	–
Denominator Exceptions	Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient's current medications list (e.g., patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status)

Additional Information

Measure Type	Process Measure
Measure Scoring	Proportion measure
Granularity	Encounter
Improvement Notation	Higher score indicates better quality
Domain	Patient Safety

Clinical Instructions

Ensure the list of current medications is always up-to-date for all patients.

Preferred Workflow

Review and update the medications in the Presenting Medications section of the encounter, as appropriate, including ALL current prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary supplements, with name(s), dosage(s), frequency, and route(s) of administration.

If the Presenting Medications section is part of the encounter outline at time of archive and close, the appropriate SNOMED Concept ID will be documented for the encounter to achieve numerator credit.

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Encounter to Document Medications	2.16.840.1.113883.3.600.1.1834

Numerator

Name	Value Set
Intervention, Performed: Documentation of current medications (procedure)	SNOMEDCT Code 428191000124101
Procedure, Performed: Documentation of current medications (procedure)	SNOMEDCT Code 428191000124101

Source(s)

eCQI CMS68