Need clarity about medication list


Local Chapter Officer
Best answers
I'm requesting some insight on how the medication list is to be used for HCC validation/abstraction.

1. Does the medication list have to be pulled into the current encounter to be used?

2. Or is it okay to use a Med Tab or Med Link that is within the EHR, but not in the progress note for that dos?

It is my understanding that the medication list has to have a diagnosis associated with that medication in addition to being date stamped for that encounter date in order to validate the diagnosis in question.

Are there any resources that I can use to confirm where the medication list has to be? In the progress note for the DOS or in a separate link or Med Tab in EHR.

Example; In HPI provider states patient takes Metformin and it's making them nauseous but doesn't state what the condition is they are taking it for. Provider says they reviewed all medication with patient. Then provider documents in A/P that patient has Diabetes but does not provide MEAT. The med list is not pulled into the encounter to see if metformin is tied to diabetes. However, there is a med tab and med link that has metformin on med list, but a diagnosis is not tied to it.

Any thoughts would be helpful. Thank you.