Medication Reconciliation
The process of creating an accurate list of all medications a patient is taking and comparing it against new orders to identify discrepancies.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Documentation
- Primary sources
- 2
- Workspace handoff
- templates →
Where this comes up
Providers meet this term in the chart and at the post-visit review — encounter notes, problem lists, medication reconciliation, signed orders, and the time/elements that defend the billed code. If documentation does not support the code, the code does not survive an audit.
Full definition
What it is in practice
CMS quality measures (e.g., MIPS Quality 130) and the Joint Commission National Patient Safety Goal require medication reconciliation at care transitions. The process should capture name, dose, route, and frequency.
How it shows up in your practice
Build medication reconciliation into the rooming workflow and discharge process. Document discrepancies addressed.
Sources
- CMS — Chronic Care Management Serviceshttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
- CMS — MIPShttps://qpp.cms.gov/mips/overview
Use the medication reconciliation template
Open templates →Related terms
- BillingTransitional Care Management (TCM)Care management following discharge from an inpatient, partial-hospital, or observation stay; CPT 99495 (moderate complexity) and 99496 (high complexity).
- DocumentationProblem ListThe structured list of active and resolved diagnoses maintained in the electronic health record.
- DocumentationDocumentation SpecificityThe level of detail in clinical documentation needed to support the diagnosis and service codes reported.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryTransitional Care Management (TCM)Care management following discharge from an inpatient, partial-hospital, or observation stay; CPT 99495 (moderate complexity) and 99496 (high complexity).
- GlossaryDocumentation SpecificityThe level of detail in clinical documentation needed to support the diagnosis and service codes reported.
- GlossaryProblem ListThe structured list of active and resolved diagnoses maintained in the electronic health record.
- SRACMS Promoting Interoperability and the Security Risk Analysis AttestationHow the CMS Promoting Interoperability program (formerly Meaningful Use) requires a HIPAA Security Risk Analysis for each EHR reporting period, what the attestation actually claims, and how CMS audits it after the fact.
- GlossaryAdvance Care PlanningDiscussion and documentation of patient's goals, values, and preferences for future medical care; billable under CPT 99497 and 99498.
- GlossaryAdvanced APMAn Alternative Payment Model that meets QPP criteria (including downside risk) and qualifies participating clinicians for a 5% lump-sum incentive payment.
- GlossaryChronic Care Management (CCM)Care management services for Medicare beneficiaries with two or more chronic conditions; billed monthly under CPT 99490 and related codes.
- GlossaryCollaborative Care Model (CoCM)Integrated primary-care behavioral-health model billable under CPT 99492-99494 and HCPCS G2214.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.