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PQRS Measure

#130Documentation and Verification of Current Medications in the Medical Record
 Description  Data Collection Sheet  Coding Specifications Registry OK.

The following codes apply for this PQRS measure:

CPT Codes

CodeModifierPOSDescription
100
102
103
104
120
124
126
140
142
144
145
147
148
160
162
164
170
172
174
176
190
192
210
211
212
214
215
216
218
220
222
300
320
322
326
350
352
400
402
404
406
410
450
452
454
470
472
474
500
520
522
524
528
529
530
532
534
537
539
540
541
542
546
548
550
560
561
562
563
566
567
580
600
604
620
622
625
626
630
632
634
635
640
670
700
702
730
740
750
752
754
756
770
790
792
794
796
797
800
802
810
820
830
832
834
836
840
842
844
846
848
851
860
862
864
865
866
868
870
872
873
880
882
902
904
906
908
910
912
914
916
918
920
921
922
924
926
928
930
932
934
936
938
940
942
944
948
950
952
1112
1120
1130
1140
1150
1160
1170
1173
1180
1190
1200
1202
1210
1212
1214
1215
1220
1230
1232
1234
1250
1260
1270
1272
1274
1320
1340
1360
1380
1382
1390
1392
1400
1402
1404
1420
1430
1432
1440
1442
1444
1462
1464
1470
1472
1474
1480
1482
1484
1486
1490
1500
1502
1520
1522
1610
1620
1622
1630
1632
1634
1636
1638
1650
1652
1654
1656
1670
1680
1682
1710
1712
1714
1716
1730
1732
1740
1742
1744
1756
1758
1760
1770
1772
1780
1782
1810
1820
1829
1830
1832
1840
1842
1844
1850
1852
1860
1916
1920
1922
1924
1925
1926
1930
1931
1932
1933
1935
1936
1951
1952
1953
1958
1960
1961
1962
1963
1965
1966
1967
1968
1969
1990
1991
1992
1996
1999
90801Psychiatric diagnostic interview examination
90802Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication
92002Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
92004Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
92012Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
92014Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
92541Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
92542Positional nystagmus test, minimum of 4 positions, with recording
92543Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording
92544Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
92545Oscillating tracking test, with recording
92547Use of vertical electrodes (List separately in addition to code for primary procedure)
92548Computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (ie, eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report;
92557Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)
92567Tympanometry (impedance testing)
92568Acoustic reflex testing, threshold
92569ACOUS RFLX DECAY
92585Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive
92588Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report
92626Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour
96116Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour
96150Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
96152Health and behavior intervention, each 15 minutes, face-to-face; individual
97001Physical therapy evaluation
97002Physical therapy re-evaluation
97003Occupational therapy evaluation
97004Occupational therapy re-evaluation
97802Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
98960Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient
99201Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
99203Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99204Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
99205Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
99211Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional
99212Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.
99213Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
99214Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99215Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99241Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99242Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
99243Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99244Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99245Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.

HCPCS Codes

CodeModifierPOSDescription
G0101Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0108Diabetes outpatient self-management training services, individual, per 30 minutes
G0270Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
G8427Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications
G8428Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given
G8429Incomplete or no provider documentation that patient's current medications with dosages (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) were assessed
G8430Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient's current medications list (e.g., patient is in an urgent or emergent medical situation)
G8507Provider documentation that patient is not eligible for patient verification of current medications
Legend:
Registry OKThis measure can be submitted through registry.
EHR OKThis measure can be submitted via Electronic Health Record (EHR).

More information on these alternative reporting mechanisms is available at:
    http://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp.
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