What Is Medication Reconciliation? The 5-Step BPMH Workflow, NPSG.03.06.01, and Quality Coding

Medication reconciliation is the structured clinical safety process of creating the most complete and accurate list of all medications a patient is currently taking—including prescription drugs, over-the-counter (OTC) medications, vitamins, and herbal or dietary supplements—and comparing that list against the clinician’s admission, transfer, and discharge orders to identify and resolve discrepancies. Mandated by The Joint Commission under National Patient Safety Goal NPSG.03.06.01 and operationalized through the Agency for Healthcare Research and Quality (AHRQ) MATCH Toolkit, medication reconciliation is a primary defense against preventable medication errors and adverse drug events (ADEs) at transitions of care.

What Is Medication Reconciliation?

Whenever a patient moves across care settings—such as emergency department presentation to inpatient admission, intensive care unit (ICU) transfer to a general medical-surgical floor, or hospital discharge to a skilled nursing facility or home—their medication regimen is vulnerable to unintentional discrepancies. Studies cited by AHRQ and the Institute for Safe Medication Practices (ISMP Targeted Medication Safety Best Practices) show that without structured reconciliation, more than half of hospitalized patients experience at least one unintended medication discrepancy at admission or discharge.

Medication reconciliation classifies discrepancies into two fundamental categories:

• Intentional Discrepancies (Documented Clinical Changes): The prescriber deliberately starts, modifies, holds, or discontinues a medication based on the patient’s acute clinical status (for example, holding a home antihypertensive during septic shock or discontinuing a nephrotoxic NSAID in acute kidney injury) and documents the rationale in the chart.
• Unintentional Discrepancies (Medication Errors): The prescriber inadvertently omits a chronic home therapy, orders an incorrect dose, route, or frequency, introduces a therapeutic duplication (such as prescribing both a brand-name and generic beta-blocker), or restarts a previously discontinued medication because the baseline medication history was incomplete.

The 5-Step Medication Reconciliation Workflow (AHRQ MATCH & BPMH)

Under the AHRQ Medications at Transitions and Clinical Handoffs (MATCH) Toolkit and Joint Commission NPSG.03.06.01, a high-reliability medication reconciliation workflow executes five sequential steps at every transition of care:

Workflow Step	Primary Clinical Responsibility	Required Documentation & Verification Standard
1. Compile the Best Possible Medication History (BPMH)	Clinical pharmacist, pharmacy technician, registered nurse, or admitting clinician	Record drug name, strength/dose, route, frequency, indication, and last dose taken using at least two sources: a structured patient/caregiver interview plus an objective external source (outpatient pharmacy fill records, Surescripts/PBM dispensation history, state PDMP, or physical prescription vials).
2. Draft Care-Setting Medication Orders	Admitting, transferring, or discharging physician / advanced practice provider	Formulate the diagnostic and therapeutic medication orders required for the patient’s current clinical phase of care.
3. Compare Lists & Screen Discrepancies	Prescribing clinician and verifying clinical pharmacist	Perform a side-by-side comparison of the BPMH against active orders in the EHR to flag omissions, commissions, dose/frequency mismatches, therapeutic duplications, and AGS Beers Criteria or STOPP/START Criteria appropriateness issues.
4. Resolve & Document Explicit Actions	Prescribing clinician	Assign an explicit status to every medication on the BPMH—Continue, Modify (dose/route/frequency), Hold Temporarily (with restart criteria), or Discontinue Permanently—and sign the reconciled order set.
5. Communicate Reconciled List at Handoff	Discharging nurse, pharmacist, and care coordination team	Provide the patient/caregiver with a plain-language written medication schedule (clearly grouping new, changed, unchanged, and stopped drugs) and transmit the reconciled list to the receiving outpatient provider or post-acute facility.

Medication Reconciliation Checklist for Transitions of Care

Clinical quality teams and clinical documentation integrity (CDI) specialists audit medication reconciliation reliability using the following operational checklist:

1. Non-Oral and PRN Agents Prompted: Did the BPMH interview specifically prompt for inhalers, ophthalmic drops, transdermal patches, topical creams, injectable biologics/insulins, as-needed (PRN) analgesics, OTC medications, and herbal supplements?
2. Fill Adherence vs. Prescribed Regimen Verified: Did the interviewer verify whether the patient is actually taking the medication as printed on the label (identifying cost-related non-adherence or self-titration before blindly ordering the label dose inpatient)?
3. High-Alert Medication Double-Check: Were anticoagulants, insulins, oral chemotherapeutics, immunosuppressants, and opioids verified with exact last-dose timestamps?
4. Zero “Resume All Home Medications” Blanket Orders: Does hospital policy prohibit blanket orders such as “resume home meds” or “continue pre-op medications” without line-by-line electronic reconciliation?
5. Discharge Teach-Back Completed: Did the patient or caregiver confirm understanding of which home medications were permanently stopped versus replaced by new discharge prescriptions?

Quality Measurement, EHR Interoperability, and Coding Integrity

In healthcare quality reporting, value-based reimbursement, and clinical informatics, medication reconciliation is measured through standardized codes and electronic data standards:

• Transitional Care Management (TCM — CPT 99495 and 99496): Under CMS rules for Transitional Care Management, medication reconciliation and management must be furnished no later than the date of the interactive face-to-face visit (within 7 or 14 calendar days of discharge) to bill CPT 99495 or 99496.
• CPT Category II Code 1111F & HEDIS MRP: Outpatient practices report CPT Category II code 1111F (Discharge medications reconciled with the current medication list in outpatient medical record) to satisfy the NCQA HEDIS Transitions of Care — Medication Reconciliation Post-Discharge (MRP) measure within 30 days of an inpatient stay.
• HL7 C-CDA and FHIR R4 Encoding: Under ONC certification criterion 45 CFR § 170.315(b)(2) (Clinical Information Reconciliation and Incorporation), certified EHRs must enable clinicians to electronically reconcile Medications, Allergies, and Problems from incoming HL7 C-CDA Transition of Care documents and normalize reconciled entries using RxNorm codes across FHIR R4 MedicationRequest and MedicationStatement resources.

Sources

• Agency for Healthcare Research and Quality (AHRQ). Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (AHRQ Publication No. 11(12)-0059). https://www.ahrq.gov/patient-safety/settings/hospital/match/index.html
• The Joint Commission. National Patient Safety Goal NPSG.03.06.01: Maintain and Communicate Accurate Patient Medication Information. https://www.jointcommission.org/standards/national-patient-safety-goals/
• Office of the National Coordinator for Health Information Technology (ASTP/ONC). 45 CFR § 170.315(b)(2) Clinical Information Reconciliation and Incorporation Certification Companion Guide. https://www.healthit.gov/test-method/clinical-information-reconciliation-and-incorporation