Section N: Medications (Drug Regimen Review)


»» Good morning, everyone. I hope you were able to take advantage of
the beautiful Baltimore summer evening last night with a walk along the harbor. It’s so beautiful. I always enjoy doing this presentation about
Drug Regimen Review. In my previous career as a Director of Nursing
in a large academic medical center it was part of my life looking at medication errors,
adverse drug events, et cetera. So it’s really a pleasure to be talking about
the Drug Regimen Review Conducted with Follow-Up for Identified Issues for post-acute care
settings. This measure is really important and critical
to the care of post-acute care patients as potential and actual patient medication errors
are prevalent among post-acute care settings and often occur during transitions in care. As we know, medication errors can lead to
medication-related adverse reactions, emergency department visits, and rehospitalizations,
and affects the patient’s health, safety, and quality of life. A 2014 Office of Inspector General Report
found that 10% of Medicare patients in IRFs experience adverse events with most of those
events being medication related. Over 45% of the adverse events and temporary
harm events were clearly or likely preventable. Medication errors and 1 out of 5 of adverse
drug events occurred during transitions between settings including admission to or discharge
from a hospital to a home or PAC setting or transfer between hospitals. Drug Regimen Review is intended to improve
patient safety and inpatient rehabilitation facility patients by identifying and addressing
potential and actual clinically significant medication issues at the time of patient admission
and throughout the patient stay. And you will hear me repeat that many times
through the presentation. The next two slides show the acronyms that
will be used throughout the presentation and I suspect are very familiar to you. So what I’m going to do in the next hour,
or when I complete this session in an hour, you’re going to have a really good understanding,
if I do a great job, of what the Drug Regimen Review Quality Measure is. You’re going to know what data elements
that you are going to be asked to code for this particular measure. You’re going to have the opportunity to go
through and practice with a number of clinical scenarios because these scenarios have been
developed based on help desk questions that we received since the measure was implemented. And you’re going to be able to describe the
Drug Regimen Review Quality Measure. The Drug Regimen Review Quality Measure is
an assessment-based, cross-setting process quality measure adopted to meet the requirements
of the Improving Medicare Post-Acute Care Transformation Act or IMPACT Act domain of
medication reconciliation. The Drug Regimen Review Quality Measure asks
the provider to complete an individual assessment of the patient to determine if there are any
problems or issues associated with the patient’s medications that need to be addressed in a
timely manner before they become worse. The emphasis is on timely intervention and
follow-up when an individual patient medication issue is identified. The Drug Regimen Review Measure was implemented
in home health in January of 2010 and for further refined in January of 2017. The Long-Term Care Hospital Quality Reporting
Program implemented the measure in July of 2018. And the skilled nursing facilities and inpatient
rehab facilities implemented the measure in October 1 of 2018. This slide shows the two admission assessment
data elements or items, and I’ll use those terms, elements and items, interchangeably
throughout the presentation, and we’ll be going through the details of these. So I will move on. N2005, Medication Intervention is the one
data element that is coded or collected on the Discharge Assessment. Next we’ll run through a number of key definitions
that you’ll need to understand in helping you to accurately code the DRR data elements. A Drug Regimen Review includes medication
reconciliation which is a review of all medications a patient is currently using and a review
of the drug regimen to identify, and if possible, prevent potential clinically significant medication
adverse consequences. So what medications are included in the Drug
Regimen Review? The Drug Regimen Review includes all medications,
and that means prescribed and over the counter, including nutritional supplements, vitamins,
homeopathic and herbal products, and administered by any route. The DRR also includes total parenteral nutrition
and oxygen therapy. The next definition is what a clinically significant
medications issue is. And a clinically significant medication issue
is a potential or actual issue that in the clinician’s professional judgment warrants
physician communication and completion of prescribed/recommended actions by midnight
of the next calendar day at the latest. I would like to make a point of emphasis in
that what CMS is asking the clinician to do, who is assessing the patient, is to ask, was
there an issue or a situation when there was a medication problem, and was it addressed? And the intent of this measure is to identify
those potential or actual clinically significant medication issues at the very first time you
identify them and actively address those problems before they become worse. And what may be a significant patient medication
issue for one patient may not be a significant medication issue for another. And those are key points. I mean, we really are looking for potential
or actual clinically significant medication issues that we can mitigate or address before
they become worse. Examples of potential or actual clinically
significant medication issues are depicted on this slide. This is not an all-inclusive list. You may come up with other things. But essentially, we’re talking about medications
prescribed despite a medication allergy noted in the patient’s medical record, adverse reactions
to medications, ineffective drug therapy, drug interactions such as drug-drug, drug-food,
and drug-disease interactions, duplicate therapy. For example, you may have a generic name and
a brand name that are both prescribed for the patient. And the five rights that all of us that our
providers know, the right dose, right patient, right route, right drug. Omissions, drugs missing from a prescribed
regimen. So if somebody has diabetes and you know they
should be on insulin and you don’t see that in the medication orders for that individual,
that is a potential or actually clinically significant medication. And non-adherence to a drug regimen. And this may be purposeful or accidental. I also want to emphasis because we get a lot
of help desk questions from IRF providers, and people actually will give us these elaborate
scenarios. I remember, Kate, my colleague who’s in the
room, five or six different scenarios and people asking us, Is this a potential or clinically
significant medication issue? And it’s not possible for CMS to provide an
exhaustive list of examples and situations that are defined as potential or actual clinically
significant medication issues. And that’s why we emphasize that it’s important
to use your clinical judgment. And what may be an issue for one patient may
not be an issue for another patient. And we’ll get into some of the particulars
about how to assist you with identifying those potential or actual clinically significant
medications, because it’s about the two-way communication. One of the things I’ve observed is that one
of the challenges providers are having is determining whether or not a clinical situation
they encounter regarding a medication is a potential or actual clinically significant
medication issue that meets the intent of this quality measure. I would like to emphasize that any of the
aforementioned examples that I gave in the previous slide must reach a level of clinical
significance that warrants notifying the physician or the physician-designee for medical orders
or recommendations by midnight of the next calendar day at the latest. Determining if very timely communication and
action is needed is key in determining whether this issue is a potential or clinically significant
medication issue. Again, please note, any circumstance that
does not require this immediate attention is not considered a potential or actual clinically
significant medication issue for the purpose of the Drug Regimen Review items. The next definition is what is two-way communication
with the physician or physician-designee? And this is, again, I just mentioned this,
a key component in completing the Drug Regimen Review data elements accurately. Two-way communication means communication
to the physician to convey and identify potential or actual clinically significant medication
issue and a response from that physician to convey prescribed/recommended actions in response
to the medication issue. In order to meet the requirements of the measure
you need to communicate and convey the information to the physician and you need to have received
a response from that physician or physician-designee so that you can address the issue. This is two-way communication. This slide shows examples of communication
that may be used in your facility to contact the physician or physician-designee. Communication can be directly to/from the
physician or physician-designee or indirectly through physician’s office staff on behalf
of the physician or physician-designee in accordance with the legal scope of practice. So as you can see from the slide, examples
of communication methods include in person, telephone, voicemail, electronic means, fax,
or any other means that appropriately convey the message of patient status. One of the frequently asked questions we receive
is, how is a physician-designee defined? According to Appendix PP of the State Operations
Manual, a physician-designee is referred to as a physician practitioner (physician assistant,
nurse practitioner, clinical nurse specialist) means the individual who has the responsibility
for the medical care of the patient. The role of physician-designee or non-physician
practitioner is defined by Federal and State licensure regulations. And I would suggest that you refer to these
regulations to determine which clinicians are licensed to act as physician-designees
in your area. The next definition is what do we mean by
medication follow-up? That is described when completing N2003. Medication follow-up is the process of contacting
a physician to communicate an identified medication issue and completing all physician
prescribed/recommended actions by midnight of the next calendar day at the latest. Next we’ll go through some coding guidance. And you’ll have the opportunity to participate
in coding some of these scenarios. In order to complete the Drug Regimen Review
items, you are going to need to refer to and review a number of patient’s medical record
sources for this information. So you say, where are you going to find this
information essential to code these three items? This slide depicts the data sources and resources
for conducting the DRR. Medical record sources include medical records
received from facilities where the patient received healthcare, the patient’s most recent
history and physical, transfer documents, discharge summaries, medication lists and
records, clinical progress notes, and other resources available. Recently, we were asked if using information
from an incident or an unusual occurrence report was an appropriate source for coding
the data items. This would be another example of one source
of information that might be helpful to you in coding these items. In addition to the medical resources listed
on this slide, discussions including discussions with the acute care hospital, other staff
and clinicians responsible for completing the Drug Regimen Review and the patient and
the patient’s family/significant other may also supplement and/or clarify the information
gleaned from the patient’s medical records. And lastly, your facility may decide to use
a specific or central means of gathering this data to make it efficient to locate information
relevant for coding this measure. And as I’ve talked with providers and as we’ve
received help desk questions, this documentation throughout the patient stay is critical in
assessing and assisting you in accurately coding these data elements, particularly the
discharge data element. The next thing is, we also receive questions
about documentation required to code the DRR data elements. And I’d like to emphasize that the information
needed to code the items, and this applies to all of IRF-PAI, should be consistent with
information recorded in the patient’s medical records. Another frequently asked question we receive
is who can complete a Drug Regimen Review? The Drug Regimen Review process is a multidisciplinary
team review of the patient’s medications. The Centers for Medicare & Medicaid Services
does not provide guidance on who can or cannot code the Drug Regimen Review items. And I would suggest that you refer to your
facility, Federal and State policies and procedures to determine which staff members may complete
a Drug Regimen Review. Each facility determines their policies and
procedures for completing this assessment and each facility provides patient care according
to their unique characteristics and standards. In other words, your patient population. Another recent question we receive is, does
it have to be a pharmacist who completes the Drug Regimen Review? And the answer to this question is no. Who completes the Drug Regimen Review as indicated
on this slide is contingent upon your facility policies and procedures, applicable Federal
and State policies that may apply and the unique characteristics and standards for your
patient population as I have mentioned. A helpful resource for regulations regarding
pharmaceutical services in IRFs is the State Operations Manual and specifically Appendix
A, which is the survey protocol regulations and interpretive guidelines for hospitals. And I have found those very helpful in reviewing
to answer this question. This slide summarizes the two Admission and
one Discharge Assessment data elements that are used to calculate the Drug Regimen Review
Quality Measure. And as I indicated, we’ll be going into those
in detail. Now we will turn to a description of each
data element for the Drug Regimen Review. As previously demonstrated, there are two
Admission Assessment data items to complete on the IRF-PAI. N2001 identifies whether a drug review was
conducted upon admission or as close to the actual time of admission as possible and whether
the clinician identified any potential or actual clinically significant medication issues. And this is what N2001 looks like on the assessment
with three response choices for coding that I will describe in a later slide. The first thing you want to do is complete
your assessment to accurately code N2001. And your manual lists all the possible potential
and actual clinically significant medication issues. So the steps for assessment, you’re going
to complete the Drug Regimen Review upon admission, and as I said, or as close to the actual time
of admission as possible to identify any potential or actual clinically significant medication
issues. You’re going to review the medical record
documentation to determine whether a Drug Regimen Review was conducted upon or as close
to the admission as possible to identify any of these possible medication issues. We’ve already gone over the medical record
resources that you would review to help assist you in coding N2001. N2001 asks, did a complete Drug Regimen Review
identify potential or clinically significant medication issues? You’re going to Code 0, no, for this item if
no clinically significant medication issues were identified during the Drug Regimen Review. You’re going to Code 1, yes, if one or more
clinically significant medication issues were identified during the Drug Regimen Review. And you would Code 9, not applicable, if the
patient was not taking any medications at the time of the Drug Regimen Review. This slide goes over the skip patterns when
you code these data elements. So if you Code 0, no, no issues found during
the review, then you’re going to skip to O0100, Special Treatments, Procedures and Programs. If you code 1, yes, issues found during review,
then you are going to continue to N2003 and code based on the medication follow-up. And you would Code 9, NA, if patient is not
taking any medications. And if you select that option then you’re
going to also skip to Section O, O0100 Special Treatments, Procedures and Programs. Now you’ll have the opportunity to practice
coding N2001 and I’ll read the scenario. And they’re also included in your packet if
you’d like to follow along. We find that it helps in terms of coding. So the first scenario, the admitting IRF nurse
reviewed and compared the acute care hospital discharge medication orders and the IRF physician’s
admission medication orders for Ms. W. The nurse interviewed Ms. W who confirmed the
medications she was taking for her current medical conditions. Upon the nurse’s request, the pharmacist
reviewed and confirmed the medication orders as appropriate for the patient. As a result of this collected and communicated
information, the registered nurse determined that there were no identified potential or
actual clinically significant medication issues. So how would you code N2001 for this scenario? And you have four options here, A, 0, no,
no issues found during review? B, 1, yes, issues found during review? C, 9, not applicable, patient is not taking
any medications? Or D, enter a dash? I’m waiting for more responses because I
know there’s about 625 people able to respond. (Laughter) In the interest of time, we will
continue to the next slide. And the correct answer is A, 0, no, no issues
found. The rationale for coding no, no issues found
is that the admitting nurse reviewed and compared the patient’s discharge medication records
from the acute care hospital with the physician’s admission medication orders, collaborated
with the pharmacist and interviewed the patient, and the nurse determined that there were no
potential or actual clinically significant medication issues. Now we’ll move on to the second scenario. Mr. C was admitted to an IRF after undergoing
mitral valve replacement cardiac surgery. The acute care hospital discharge information
indicated that Mr. C had a mechanical mitral heart valve and was to continue receiving
anticoagulation medication. While completing the review in comparison
of the patient’s discharge healthcare records from the acute care hospital with the IRF
physician’s admission medication orders, an RN noted that the admitting physician ordered
the patient’s anticoagulation medication to be held if the International Normalized Ratio
INR was below 1.0. However, the physician’s admission note indicated
that the desired therapeutic INR parameters for Mr. C were 2.5 to 3.5. The RN questioned the INR level listed on
the admitting physician’s order based on the therapeutic parameters of 2.5 to 3.5 documented
in the physician’s admission note. This prompted the nurse to call the physician
immediately to address the issue. In this scenario, did a complete Drug Regimen
Review identify potential clinically significant medication issues? Okay. And again, in the interest of time, we’ll
move on. And the correct answer is, B, 1, yes. And everyone who responded was correct. And the rationale for coding this scenario,
1, yes, issue found during the review is that the admitting RN reviewed and compared the
patient’s discharge healthcare records from the acute care hospital with the IRF physician’s
medication orders. The RN identified a discrepancy between the
physician’s ordered INR level of 1.0 for this patient and in the IRF standard therapeutic
range of 2.5 to 3.5. The RN considered this to be a potential clinically
significant medication issue because of the difference and the admitting IRF physician’s
order was to hold the anticoagulation medication for an INR of 1.0 which is below the IRF’s
established therapeutic INR parameters which could lead to potential clotting issues. Now we’ll move on to the second admission
data element which is N2003, Medication Follow-Up. N2003 identifies whether the facility contacted
a physician and completed all physician prescribed/recommended actions by midnight of the next calendar day
in response to all potential or actual clinically significant medication issues identified upon
admission. N2003 asks, did the facility contact a physician
or physician-designee by midnight of the next calendar day and complete prescribed/recommended
actions in response to the identified potential or actual clinically significant medication
issue? And you’re going to code this item either
no or yes for the second admission item. N2003 is coded if a potential or actual clinically
significant medication issue was identified during the admission Drug Regimen Review. So in other words, if you responded to N2001
equals 1, yes, then you would move on to N2003 and respond to that. The steps for addressing this second DRR admission
question are to accurately code N2003, you need to determine, and this is key, whether
two-way communication between the clinician and the physician was completed by midnight
of the next calendar day and all physician prescribed/recommended actions were completed
by midnight of the next calendar day at the latest. This criteria needs to be met for all potential
and actual clinically significant medication issues that were identified upon admission. This slide depicts the coding instructions. You’re going to Code 0, no, for N2003 if all
physician or physician-designee prescribed/recommended actions were not completed by midnight of
the next calendar day. You’re going to Code 1, yes, if the two-way
communication and completion of the prescribed/recommended actions occurred by midnight of the next calendar
day after the potential clinically significant medication issue was identified. This next slide depicts examples of what we
mean by midnight of the next calendar day. So on example 1, I’m just going to read them,
a clinically significant medication issue is identified at 10:00 a.m. on May 1st. The physician or physician-designee prescribed/recommended
action is completed on or before 11:59 p.m. on May 2nd. In the second example, a clinically significant
medication issue is identified at 11:00 p.m. on May 1. The physician or physician-designee’s prescribed/recommended
action is completed on or before 11:59 p.m. on May 2nd. I would also like to share with you a few
examples of why you would code 0, no, for N2003. So the first example is the clinician did
not communicate all identified clinically significant medication issues to the physician
or physician-designee until after midnight of the next calendar day. So you’re going to code N2003, 0, no. Another example is the clinician communicated
all identified clinically significant medication issues to the physician by midnight of the
next calendar day but the clinician did not receive a response from the physician or physician-designee
to communicate prescribed/recommended actions until after midnight of the next calendar
day. So you would also code N2003, 0, no. The next slide shows an example of when N2003
can be coded 1, yes. And so the example is, if the physician or
physician-designee recommends an action that will take longer than midnight of the next
calendar day to complete, then you would code N2003, 1, yes, should still be entered as
long as by midnight of the next calendar day the clinician has taken the necessary measures
to comply with the recommended action. So in this slide the physician writes an order
instructing the clinician to monitor the medication issue over the weekend and call if the problem
persists. And on this slide is another example of when
it’s appropriate to code N2003, 1, yes. And this is if the physician or physician-designee
communicates that no actions are necessary regarding the reported issue, then you would
still code N2003, 1, yes and it should be entered as long as all communications took
place before midnight of the next calendar day. The next slide shows another one of those
frequently asked questions that we received. And the question is, if a physician orders
medications on admission and the pharmacist contacts the physician and resolves the question
or potential issue on the same day, is this still considered an issue? If the clinician determines that the issue
was clinically significant, in this case the pharmacist communicated to the physician and
resolved the issue by midnight of the next calendar day, then this meets the requirements
for coding N2001, yes, issues found during the admission review and N2003, 1, yes, Medication
Follow-Up on the Admission Assessment. And what’s
important with coding N2003 is that two-way communication occurred between the physician
and the pharmacist in this example. The next question is, if a facility-based
physician-designee performed the Drug Regimen Review, identified a medication issue, and
addressed it without needing to communicate with another physician/physician-designee,
how should N2001 and N2003 be coded? The definition of a clinically significant
medication issue requires the identification of medication issue that warrants contacting
a physician or designee, i.e, this two way communication that I’ve been talking about,
in a timely manner and addressing all physician or physician-designee prescribed/recommended
actions by midnight of the next calendar day at the latest. In this scenario, since no two-way communication
was warranted, this is not considered a clinically significant medication issue for the purposes
of completing N2001. The next provider question is, is there a
specific timeframe that the admission Drug Regimen Review must be completed for N2001
and N2003? We are often asked if there is a specific
timeframe for completing the admission Drug Regimen Review. We ask that as IRF providers you follow your
best practices by conducting the Drug Regimen Review as soon after the patient’s admission
as possible. As I indicated in the introduction for this
session, we know that medication errors occur during transitions of care. So it’s really important to follow those
best practices that we do know when our patients are admitted. And we also know that medication administration
is a huge component of patient care in healthcare. I’d also like to emphasize that facilities
deliver care, as I’ve said in the past, according to their patient population and that each
facility determines its policies and procedures for documenting medication issues and the
processes used to notify physicians of any potential medication issues. The next question is, what are some examples
of clinically significant medication issues? And the answer is located here on the slide,
but we also went through these in a previous slide. And again, I emphasize that you’re going to
use your clinical judgment to determine if an identified medication issue would be considered
a potential or actual clinically significant medication issue that would require two-way
communication with the physician/physician-designee and completion of prescribed/recommended actions
by midnight of the next calendar day at the latest. Any circumstance that does not require this
immediate attention is not considered a potential or actual clinically significant medication
issue. A potential clinically significant medication
issue is an issue to reemphasize that the care provider’s clinical judgment requires
that notification by midnight of the next calendar day at the latest. Now we’ll move on to practice coding scenario
Number 3. And this will give you an opportunity to code
N2003. Mr. B was admitted to the IRF following a
hip fracture and with an active diagnosis of pneumonia and atrial fibrillation. The acute care facility medication record
indicated that Mr. B was on a 7-day course of antibiotics and he had 3 remaining days
of his treatment plan. The IRF pharmacist reviewed the discharge
records from the acute care facility and the IRF admission medication orders. The pharmacist noted that Mr. B had an order
for an anticoagulant medication that required INR monitoring as well as the antibiotic. On the date of admission, the IRF pharmacist
contacted the IRF physician caring for Mr. B and communicated a concern about potential
increase in the patient’s INR with this combination of medications which placed the patient at
greater risk for bleeding. The IRF physician provided orders for laboratory
testing so that the patient’s INR levels would be monitored over the next three days starting
that day. Keep that in mind. Starting that day, how you would respond to
this scenario? However, the first INR laboratory test did
not occur that day, and instead occurred after midnight of the next calendar day, meaning,
the IRF physician’s recommended actions were not completed by midnight of the next calendar
day. So for this scenario, you are first going
to code N2001 for this scenario. Did a complete Drug Regimen Review identify
a potential clinically significant medication issues? And you have your four response options. And again, for the sake of timing, because
almost 100 people have responded, yes, the correct answer, we’ll move on. Now I’d like you to consider what happened
once the potential medication issue was identified for the purposes of coding N2003, Follow-Up. Did the facility in this scenario contact
a physician or physician-designee by midnight of the next calendar day and complete prescribed/recommended
actions in response to the identified potential clinically significant medication issues? And your response options are A, no. B, yes. Or C, enter a dash. Okay. We’ll move on to the correct answer. And the correct response is A, no, which this
is great. It means I’m doing a better job because this
has been a scenario that people have been a little tripped up on. So hopefully our clarification is helping
in terms of how you would code this particular type of scenario. So in summary, for this clinical scenario,
you’re going to code N2001, yes, issues found during review and then you’re going to code
N2003, 0, no. And the rationale for this is that a potential
clinically significant medication issue was identified during the Drug Regimen Review. The staff did contact the physician prior
to midnight of the next calendar day but did not complete to the extent possible the physician
prescribed actions related to the INR laboratory test until midnight of the next calendar day. In other words, the INR test was not initiated
on the day that the concern was communicated as ordered by the physician. Well, we’ll go on to practice coding Scenario
4. And you’ll also have the opportunity to code
both admission data elements. Ms. K was transferred from an acute care hospital
to an IRF with discharge paperwork. Her medical records indicate that she is on
a direct oral anticoagulant for atrial fibrillation as well as aspirin, and a P2Y12 inhibitor
clopidogrel for recent cardiac stent placement. The admitting physician recalls patient recent
guidelines suggesting that triple therapy with a DOAC, aspirin, and P2Y12 inhibitor
is not recommended due to the excess risk of bleeding. The admitting physician immediately calls
and speaks with the patient’s cardiologist who agrees with the recommendations and discontinues
the aspirin, retaining the P2Y12 inhibitor and low dose DOAC in accordance with recent
guidelines. How would you code N2001 on the Admission
Assessment for this scenario? Okay. We’re trending towards the correct response. So we’ll continue. B, 1, yes is the correct answer as there were
issues found during the review. Next, how would you code N2003? Did the facility contact the physician or
designee by midnight of the next calendar day and complete prescribed/recommended actions
in response to the identified potential clinically significant medication issue? Would you answer it O, no? B, 1, yes? Or enter a dash? And in the interest of time, we’ll move on
to the slide with the correct answer. And B, 1, yes is the correct answer. So to summarize this scenario, you would code
both N2001 and N2003, 1, yes, on the Admission Assessment. The rationale for this is that using clinical
judgment during the Drug Regimen Review, the physician identified a potential clinically
significant medication issue, a medication contraindication with risk for excess bleeding. Two-way communication occurred between that
physician and the patient’s cardiologist and the identified clinically significant medication
issue was resolved by midnight of the next calendar day. In this case, before midnight of the next
calendar day, the admitting physician contacted the patient’s cardiologist regarding the medication
contraindication and the medication orders were changed. The next Scenario, 5 is another one for coding
N2001 and N2003. Mr. D is in severe pain on admission to an
IRF following his recent surgery for spinal stenosis. He is scheduled to receive two tablets of
extra strength acetaminophen every 6 hours. In addition, other as-needed PRN medications
are ordered including ibuprofen and hydrocodone-acetaminophen. A Drug Regimen Review is completed later that
afternoon which identifies that the patient is scheduled to receive the maximum dose of
acetaminophen for a 24-hour period but also has orders for hydrocodone-acetaminophen PRN
which could potentially result in an acetaminophen overdose. The clinician completing the Drug Regimen
Review contacts the IRF physician who states she will review the medications later today
and make necessary changes. Following the facility’s protocol, the clinician
documents the conversation with the IRF physician. However, the physician forgets to change the
order that day. Two days later, the physician is paged to
assess Mr. D for ongoing pain and on review of his current medication list sees that she
did not discontinue, hydrocodone-acetaminophen. She immediately discontinues this medication
and initiates an alternative PRN medication that does not contain acetaminophen. How would you code N2001 on the Admission
Assessment for this scenario? We’ll move on to the next slide. And the correct answer is B, 1, yes, issues
found during the review. How would you code N2003 on the Admission
Assessment for this scenario? A, 0 no? B, 1, yes? Or enter a dash? And moving on to the next slide. The correct answer is A, 0, no. To summarize the coding for this scenario,
you would code N2001 as yes, issues were found during the review, and N2003, 0, no. And the rationale for this is that during
the Drug Regimen Review, using clinical judgment, the clinician identified a potential clinically
significant medication issue and that was the potential for an acetaminophen overdose
that warranted notification and communication with the physician/physician-designee for
recommendations or orders before midnight of the next calendar day. The identified clinically significant medication
issues’ potential for acetaminophen overdose was not resolved by midnight of the next calendar
day. In this case, the IRF physician did not review
the medications and make necessary changes until two days later. Now we’ll move on to N2005, Medication Intervention
which is the one data element for the Discharge Assessment. And N2005 asks, did the facility contact and
complete physician or physician-designee prescribed/recommended actions by midnight of the next calendar day
each time, and I emphasize that, each time throughout the patient stay potential or clinically
significant medication issues were identified since the admission? The observation period for this item is from
the date of admission through discharge. And that’s why that point I made earlier in
terms of, one of the previous slides that we have, documenting information in the patient’s
medical record to accurately code the IRF-PAI is critical because as we know, IRF patients
have an average 14 day length of stay. So a lot can happen between admission and
discharge, hopefully not. The coding options for N2005 are 0, no? 1, yes? Or 9, not applicable, which means there is
no potential or actual clinically significant medication issues identified since admission
or the patient is not taking any medications? The steps for assessment for this item are
very similar in terms of N2001 and N2003 and actually are going to use the same source
as a medical record documentation to assist you with accurately coding N2005. Again, in the interest of time, we’ve gone
over the possible resources in terms of reviewing the information where you might receive the
information to accurately code N2005. The second step in making the assessment to
accurately code N2005 is to determine if both criteria were met for all potential and actual
clinically significant medication issues that were identified upon admission or at any time
throughout the patient stay. And those two criteria are that the two-way
communication between the clinician and the physician or designee was completed by midnight
of the next calendar day and all physician prescribed/recommended actions were completed
by midnight of the next calendar day, admission through discharge. To emphasize, N2005 includes all Drug Regimen
Review information that you collected and coded from when the patient was admitted throughout
that patient stay, admission through discharge. This slide depicts the coding instructions
and the details of how to accurately code this item. You’re going to code 0, no, if the facility
did not contact the physician and complete prescribed/recommended actions by midnight
of the next calendar day each time a potential or actual clinically significant medication
issue was identified since admission. Some examples for when you would code N2005,
0, no include at admission or if at any time during the patient stay the clinician did
not communicate all identified potential or actual clinically significant medication issues
to the physician until after midnight of the next calendar day. So you would code N2005 as 0, no. Another example is at admission or at any
time during the patient stay, the clinician communicated to the physician/physician-designee
all identified potential or actual clinically significant medication issues, but the physician
or physician-designee did not respond until after midnight of the next calendar day. Again, you would code N2005, 0, no. And the last example is, at admission, or
at any time during the patient stay, the clinician did not complete all physician prescribed/recommended
actions for all identified potential or actual clinically significant medication issues by
midnight of the next calendar day. So those are three examples when it’s appropriate
to code N2005, 0, no. So when do you code N2005, 1, yes? You would code N2005, 1, yes, if the facility
contacted the physician and completed prescribed/recommended actions by midnight of the next calendar day
each time a potential or actual clinically significant medication issue was identified
since admissions. So a few examples of when you would code this
data element 1, yes. The first example, at admission and at anytime
throughout the patient stay, the clinician contacted the physician-designee regarding
all identified, potential, or actual clinically significant medication issues and the physician/physician-designee
communicated to the clinician that no actions were necessary regarding the reported issues. All communications took place before midnight
of the next calendar day. So coding N2005, 1, yes would be appropriate
in this scenario. Coding 9, not applicable, if there were no
potential or actual clinically significant medication issues identified at admission
or throughout the patient stay, or the patient was not taking any medications at admission
or at anytime throughout the stay. A point of emphasis for coding 9, not applicable,
if the patient that’s being discharged is not taking any medications at the time of
discharge, however, was taking medications early in the stay, you would not code this
data element as 9, not applicable. So again, when you’re coding N2005, you really
are going back to what was the situation upon admission and how did you code N2001 and how
did you code N2003? A few definitions here about coding N2005. I’d like to emphasize that throughout the
stay includes admission through and up to the time of the patient’s discharge. Drug Regimen Review is conducted upon admission
and clinicians complete actions recommended by a physician during the timely follow-up
which are completed each time potential or actual clinically significant medication issues
are identified throughout the stay. And timely for the Drug Regimen Review refers
to midnight of the next calendar day at the latest. And I’m going to move quickly because we only
have about 7 minutes left. So one of the provider questions that we get,
and I really like this one because I think it’s a good example, if a provider coded item
N2003 as 0 on the Admission Assessment indicating that the required follow-up action did not
take place, is there a way for the facility to code N2005 as 1, yes? Now based on what you’ve heard from me so
far this morning, what do you think the answer is to that question? I’m trying to be a little interactive here. (Laughter) And it’s still only mid morning. So the answer of course is, no. N2005 would also be coded 0, no. This means that if only one of the multiple
potential clinically significant medication issues at admission was not followed up by
midnight of the next calendar day, the facility should code N2003 admission as 0, no. And then N2005 again, admission through discharge,
because N2005 follows how you coded N2001 and N2003 would be 0, no. Even if only one of multiple medication issues
identified at admission was not addressed by midnight of the next calendar day throughout
the stay, N2003 is always coded, 0, no, indicating the required follow-up did not take place
for the potential clinically significant medication issues. Okay. In five minutes we have about 3 scenarios
to go through. So this is practice coding N2005 but you’re
also going to have the option to code N2001, N2003 and N2005. At discharge from the IRF, the discharging
licensed clinician reviewed Mrs. T’s medical records which included admission through her
entire stay at the IRF. The clinician noted that a clinically significant
medication issue was documented during the Admission Assessment. At admission, Mrs. T was taking two antibiotics,
an antibiotic prescribed during a recent acute care hospital stay that the IRF physician
had included in her IRF medication orders and a second antibiotic prescribed by the
IRF physician upon admission that is known for drug-induced nephrotoxicity, Mrs. T has
renal disease. Mrs. T’s medical records further indicated
that an IRF nurse had attempted to contact the assigned IRF physician several times about
this clinically significant medication issue. After midnight of the second calendar day,
the IRF physician communicated to the nurse via telephone order to administer a newly
prescribed antibiotic in addition to the previously prescribed antibiotic. The nurse implemented the physician’s order. Upon further review of Mrs. T’s medical records,
the discharging nurse determined that no additional clinically significant medication issues had
been recorded throughout the remainder of Mrs. T’s stay. So how would you code N2001 on the Admission
Assessment for this scenario? We are trending towards the correct answer. So given the timeframe, we’ll move on to the
correct answer. And the correct answer is, B, 1, yes. How would you code N2003 for this scenario? A little uncertainty about this response. But we’ll move on to the next slide. The correct answer is A, 0, no. How would you code N2005? Okay. We’ll move on to the correct answer. And the correct answer is, A, 0, no. To summarize this coding, N2001, yes, issues
found during review and N2003, 0, no and N2005, 0, no. The facility did not contact the physician
or designee and complete prescribed/recommended actions by midnight of the next calendar day
each time clinically significant medication issues were identified at admission and throughout
the patient stay admission through discharge. Coding of N2005 includes all potential or
actual clinically significant medication issues identified at admission or at anytime throughout
the patient stay that were or were not communicated to the physician/physician-designee with prescribed/recommended
actions completed by midnight of the next calendar day. Although no potential or actual clinically
significant medication issues were identified by the nurse during the remainder of the stay,
notification of the medication issue identified at admission despite repeated communication
attempts by the nurse was not addressed by the physician-designee by midnight of the
next calendar day. I only have about a minute left. So I think what we’re going to do is we’ll
go through clinical Scenario 7 and then I want to move on briefly and go over the quality
measure because that’s important. And I know that we’re taking a break after
this so I apologize, Brigitte, if I go over a minute or two. In the next scenario, you’re going to be asked
to code all three data elements again. Mr. H is admitted to the IRF and his healthcare
records are transferred from the discharge in acute care hospital. The IRF physician notices that the most recent
Medication Administration Record from the acute care hospital indicates that the patient
was receiving long-acting insulin. However, the final discharge medication that
was sent with the patient does not include this medication. Within an hour, the IRF physician telephones
the acute care hospital and speaks to the discharging clinician who confirms that the
patient should be prescribed his medication due to his history of diabetes. The IRF physician orders the long-acting insulin
immediately after the telephone call with the acute care discharging clinician and no
other potential clinically significant medication issues were identified during the remainder
of the patient stay. How would you code N2001 for this scenario? We’re trending towards the correct answer
so I’m going to move on to the next slide in the interest of time. And yes, the correct answer is B, 1, issues
found during the review. How would you code N2003? Again, we’ll move on to the next slide because
we’re trending towards the correct response, which is B, 1, yes. And how would you code N2005? Again, trending to the correct answer. So to summarize for this scenario, N2001,
the correct answer is yes. N2003, the correct answer is 1, yes. And Discharge Assessment, N2005, 1, yes, is
the correct answer. And again, for the interest of time, during
the Drug Regimen Review, the IRF physician identified the potential clinically significant
medication that warranted communication with the physician for recommended orders before
midnight of the next calendar day. The identified clinically significant medication
issue was resolved by midnight of the next calendar day. In this case, before midnight of the next
calendar day, the IRF physician followed up with the acute care discharging clinician
to resolve the discrepancy and the IRF physician ordered the needed medication. The only clinically significant medication
issue identified in admission was resolved by midnight of the next calendar day and no
other potential clinically significant medication issues were identified during the remainder
of the patient stay. So I’m going to skip Scenario 8 because I
am out of time. But I would ask that you practice it or take
it upon yourself to review it. So we’ll just move on. Okay. So these next couple of slides, I’m just going
to present the Drug Regimen Review Conducted with Follow-Up for Identified Issues. The Drug Regimen Review Conducted with Follow-Up
for Identified Issues reports the percentage of patient stays in which a Drug Regimen Review
was conducted at the time of admission and timely follow-up with a physician or physician-designee
occurred each time potential or actual clinically significant medication issues were identified
throughout the patient stay. A patient stay is the period of time between
a patient’s admission date into an IRF and date of discharge. Interrupted stays of 3 calendar days or less
are included as part of the patient stay. As previously described, timely for the Drug
Regimen Review refers to midnight of the next calendar day at the latest. This is a very dense slide so I’m going to
walk through it very quickly. As I indicated, the Drug Regimen Review is
a process quality measure that is calculated as a facility-level observed score. And to calculate the percentage of patients
that successfully met the Drug Regimen Review measure criteria. We set up a fraction which is depicted on
this slide. And this fraction is comprised of the numerator
and the denominator. So on the bottom of this slide you see denominator
is comprised of the number of patient stays during the reporting period. The numerator, which is the top part of this
slide includes only those patient stays in the denominator that meet the following two
criteria. So the first criteria is the facility conducted
a Drug Regimen Review on admission which resulted in one of the three following scenarios. The first scenario is no potential and actual
clinically significant medication issues were found during the review, so if N2001 is coded,
0, or the second criteria potential and actual clinically significant medication issues were
found during the review. So N2001 equals 1, and then a physician or
physician-designee was contacted and prescribed/recommended actions were completed by midnight of the
next calendar day. In other words, N2003 equals 1, or the patient
was not taking any medications, N2001 equals 9, not applicable. The second criteria that’s included in the
numerator is appropriate follow-up occurred each time a potential or actual clinically
significant medication issue was identified during the stay. So N2005 equals 1 or no potential or actual
clinically significant medication issues were identified since the admission or patient
was not taking any medications. So if you coded, N2005 equals 9. Then to calculate the facility-level observed
score, you’re going to divide the facility’s numerator count by its denominator count to
obtain the facility-level score. That is, you divide the result of step 2 by
the result of step 1 and then multiply by 100 to obtain a percent value. The Drug Regimen Review Quality Measure is
a process measure as I’ve indicated and therefore it is not risk-adjusted or stratified and
there are no denominator exclusions. For the sake of time, I am not going to do
the summary slides and would just, if you would like to review them, the last few slides
summarize what I’ve presented today. We’ve gone over the intent of the Drug Regimen
Review, how to code both the admission and discharge data elements, and then also I’ve
provided a very brief overview of the quality measure. And I apologize for moving into your break
time but thank you for your attention.

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