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Medication Review

Clinical Basis

Creating an accurate medication list is important to patient safety. An annual comprehensive review of all medications (prescription and non-prescription) and supplements being taken can help reduce medication errors.

Patients may use multiple pharmacies, have co-morbidity factors and multiple prescribing healthcare providers. Medication errors can be avoided by:

• Capturing a complete and accurate list of the medications patients are taking and comparing this list with documentation in the patients’ medical record
• Physically looking at the patients’ medications at each ambulatory care visit – especially post-facility discharge – and reviewing the physicians’ admission, transfer and/or discharge orders in inpatient settings.

Clinical Guidelines

• Arrange to have at least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year.
• Instruct your patients to bring all of their medications – including over-the-counter medications and supplements – to every physician visit, especially post-facility discharge.
• Review patients’ medications at every visit.
• Encourage your patients to use a single pharmacy to reduce potential drug interactions.
• Reference Eric Coleman’s Transitions Program¹ at the time of hospital discharge:
• Medication self-management
• Maintenance of personal health record
• Primary care physician follow-up
• Alertness to red flags

Documentation and Coding Guidance

Documentation should include a description of the counseling provided and any medication counts (and their significance), as well as documentation that you reviewed or reconciled in the patients’ medication list. If any medications are changed or discontinued, this should be documented also.

• The presence of a medication list in the medical record is represented by 1159F.
• A comprehensive review of all medications by a prescribing practitioner or clinical pharmacist (such as, prescriptions, OTCs, herbal therapies and supplements) documented in the medical record, as applicable, is represented by 1160F.

¹See http://www.caretransitions.org/ for information about this program.

CPT II Codes

1159F - Medication list documented in medical record

1160F - Medication list documented in medical record

 

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