Thank you for your question about CMS68v12: Documentation of Current Medications in the Medical Record. As noted in the measure specifications, encounters with documentation of a medical reason for not documenting, updating, or reviewing the patient’s current medication list qualify as a measure exception. The value set “Medical Reason” (OID: 2.16.840.1.113883.3.526.3.1007) does contain SNOMEDCT (183932001) Procedure contraindicated (situation) as a valid code for the denominator exception. We are not able to provide prescriptive mapping guidance. It is best to consult with your clinical partners to determine whether SNOMEDCT 183932001 is a clinically appropriate code for patients with dementia or who cannot safely provide medication details during the encounter. If mapping is conducted, you should maintain documentation in case of a CMS audit.

We often have elderly patients who come for appointments without family and without a list of their medications and they are unable to effectively assist in the reviewing of their current medication list with the EC because they are suffering from mild senior dementia, confusion or memory issues. It is impossible to get a try review of the patients current medications because of their limited mental capacity. We document this in the chart but we believe that the EC should not be penalized for being unable to do this as this is a Medical Reason.