M2003: CMS OASIS Q&As

When completing M2003 - Medication Follow-up, if the physician/allowed practitioner or physician designee responds by midnight of the next calendar day and there is a resolution to the clinically significant medication issue, Response 1 - Yes should be entered. In your scenario, you describe a situation where the physician was contacted and informed of the medication issue, but then due to the contacted physician’s unfamiliarity with the patient, you were directed to contact the primary care practitioner on Monday. In cases where the physician/allowed practitioner (or physician-designee) recommends an action that will take longer than the allowed time to complete, then Response 1 - Yes should be entered as long as by midnight of the next calendar day, and within the assessment timeframe the agency has taken whatever actions are possible to comply with the recommended action.

M2003 - Medication Follow-up, is only collected at the SOC and ROC. The item must be answered within the timeframe allowed at the SOC/ROC to ensure compliance with the Condition of Participation regarding the completion of the comprehensive assessment. If a problem is identified, the communication and completion of prescribed/recommended actions to the extent possible must occur by midnight of the next calendar day after identification and before the end of the allowed timeframe in order to answer 1 - Yes. If a medication issue is identified on day 5 after the SOC, the physician is contacted by midnight of the next calendar day and responds back with a plan to resolve the problem on day 6 after the SOC, this 2-way communication could not be captured at the SOC.

M2003 - Medication Follow-up identifies if potential or actual clinically significant medication issues identified though the drug regimen review were communicated to the physician/allowed practitioner (or physician-designee) with prescribed/recommended actions completed by midnight of the next calendar day. In the scenario described, the communication occurred, and the prescribed/recommended action (communicate medication change to patient) was completed prior to midnight of the next calendar day after the issue was identified. Code M2003 as 1 - Yes. It is not necessary for the issue, in this scenario the rash, to be resolved by midnight of the next calendar day, as long as the physician communication and completion of the prescribed/recommended actions were completed.

In order to select response 1 - Yes to M2003 - Medication Follow-up, the physician must have been notified by midnight of the next calendar day regarding all clinically significant medication issues that were identified during the SOC/ROC comprehensive assessment. In addition to the physician notification, you must have completed any prescribed/recommended actions to the extent possible by midnight of the next calendar day to answer 1-Yes. In order to select response 1 - Yes for M2005 - Medication Intervention, all clinically significant medication issues that were identified at the time of or at any time since the SOC/ROC must have been resolved in the same manner as stated above.

The reference to “in accordance with the legal scope of practice” refers to the State requirements defining who can take orders from physicians. Each HHA should have a policy and procedure consistent with State law that describes who can take orders from the physician. It is important to understand that all orders must come from the physician/allowed practitioner and eventually be signed by the physician/allowed practitioner.

M2003 - Medication Follow-up and M2005 - Medication Intervention ask if two-way communication and completion of any prescribed/recommended actions occurred by midnight of the next calendar day when a clinically significant issue is identified. For M2003, the timeframe is “by midnight of the next calendar day” from the time the potential clinically significant medication issue was identified and within the Start of Care (SOC) or Resumption of Care (ROC) comprehensive assessment timeframe. For M2005, the timeframe is “by midnight of the next calendar day” each time a potential clinically significant medication issue was identified at the time of, or at any time since, the most recent SOC/ROC assessment.