Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it “squares” with all the other medication information).

Definition of Terms. Medication Reconciliation -- The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider.

This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.

1111F Discharge medications are reconciled with the current medication list in outpatient medical record. Can be billed alone since a face-to-face visit is not required. Note: CPT® II code 1111F can be billed once per discharge.

Requires documentation of medication reconciliation documented on the date of the discharge through 30 days after the discharge (31 days total).

Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care.