CMS68v9 – Documentation of Current Medications in the Medical Record

All visits occurring during the 12 month measurement period for patients aged 18 years and older.

– DENOMINATOR EXCEPTION

Medical Reason:
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.

– NUMERATOR

Eligible professional or eligible clinician attests to documenting, updating or reviewing the patient’s current medications using all immediate resources available on the date of the encounter.

This list must include ALL known:

• Prescriptions
• Over-the-counters
• Herbals and vitamin/mineral/dietary (nutritional) supplements
• Medications’ name, dosages, frequency and route of administration

For Denominator:_
All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period.

The documentation of the first encounter takes place when one visit code gets attached with the patient’s eSuperbill/ charge.

For Numerator:

To perform the following procedure, navigate to Patient > Clinical > Evaluations.

• Current Medications Documented SNMD
• Medications Encounter Code Set

Denominator Exceptions:

Medical Reason:
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. To record medications, navigate to Patient > Clinical > Medications.