CV ASC Registry Education-Seq#10205 (Discharge Medications Prescribed)

Video Transcription

Sequence 10205, Discharge Medications Prescribed, is capturing if a certain medication was prescribed,  not prescribed, or was not prescribed for either a medical or patient reason on discharge. Yes, would be selected if a certain medication was prescribed on discharge.  No, no reason would be selected if a certain medication was not prescribed post-procedure or for discharge, and there was no mention of a reason why it was not ordered within  the medical documentation. No medical reason would be selected if a certain medication was not prescribed post-procedure  or for discharge, and there was a reason documented related to a medical issue or concern for not prescribing that medication.  Medication that is acceptable to code no medical reason must include a specific reason the medication was not prescribed.  Examples of acceptable documentation include physician documentation that the medication was not prescribed due to an existing medical condition, an intolerance or allergy to a  medication, active bleeding, oral anticoagulation therapy as pre-arrival medication, as a medical exception to prescribing aspirin.  Examples of acceptable documentation continued include specific reasons for not prescribing one medication would apply to the entire class.  This gives the physician credit for addressing and assumes reasons provided applies to the entire class.  As an example, documentation of no plavix due to bleeding risk supports coding no medical reason for all P2Y12 inhibitors.  Another example of acceptable documentation continued includes general clinician documentation, patient contraindication, without specifying the exact contraindication.  As an example, documentation of patient has contraindication to aspirin supports coding no medical reason for aspirin.  Documentation that is either absent or too generic or general is not acceptable to support coding.  The physician's documentation may indicate a decision was made not to prescribe a specific medication, however, the reason or contraindication is not implicitly provided.  No patient reason would be selected if a certain medication was not prescribed post-procedure or for discharge and there was a reason documented related to the patient's preference.

Video Summary

Sequence 10205, Discharge Medications Prescribed, checks if prescribed medications post-discharge had any medical or patient reasons for not being ordered. "Yes" indicates a prescribed medication, while "No" indicates a medication not prescribed without stated reasons. If no medical reason was given, but a patient-related reason was documented, "No patient reason" would be selected. Specific justifications for not prescribing medications are necessary, such as existing medical conditions, allergies, or patient preferences. Vague or absent documentation is not acceptable for coding. The physician's detailed reasoning for not prescribing certain medications is crucial for accurate coding in discharge summaries.

Keywords

Discharge Medications Prescribed

Prescribed Medications

Medical Reasons

Patient Reasons

Coding in Discharge Summaries