A 74-year-old patient is discharged from the hospital after a heart failure admission with a new beta blocker, a doubled diuretic dose and instructions to stop the NSAID she had been taking for her knees. She comes to her primary care office six days later. The medical assistant asks "any changes to your medications?" and she says no, because in her mind the hospital changed them, not her. The chart still shows the old diuretic dose and the NSAID. The physician, working from the chart, tells her to keep everything the same.
That visit would have counted as a medication reconciliation in most practices' EHR reports, because someone clicked "medications reviewed." It was not one. Medication reconciliation is the act of comparing the list you have with the list the patient is actually taking, from every source you can get, resolving each difference and recording what you decided. It is one of the highest-value things a primary care practice does and one of the least consistently done, which is why NCQA made it a core requirement for Patient-Centered Medical Home recognition and why Medicare built it into transitional care management.
This piece describes a medication reconciliation workflow that a small practice can run every day: who does each step, what triggers it, what the note must contain and which numbers prove it happened. It is written for the practice going through PCMH recognition or preparing an annual review, and for any practice that wants the work to be real.
Key takeaways
- NCQA PCMH criteria KM 14 (medication reconciliation for patients received from care transitions) and KM 15 (an up-to-date medication list) are both core, and the performance threshold rose to more than 90 percent of patients when Version 11.1 took effect on January 1, 2026.
- Reconciliation is a comparison with a documented outcome, not a review; the note needs the source lists, each discrepancy found and what was done about it.
- Split the work: staff collect and compare, a nurse or pharmacist reconciles, the clinician resolves clinical discrepancies and signs. No single role can do all of it well at scale.
- The same reconciliation that satisfies KM 14 is a required element of transitional care management codes 99495 and 99496 and supports the CPT II code 1111F for post-discharge measures.
What NCQA is asking for
Under the NCQA PCMH standards, the Knowing and Managing Your Patients concept contains a medication cluster. KM 14 requires the practice to review and reconcile medications for patients received from care transitions: hospital discharges, emergency department visits, skilled nursing stays, and referrals back from specialists who changed therapy. KM 15 requires the practice to maintain an up-to-date medication list for its patients. Both are core criteria, meaning they must be met for recognition, and both are measured as a percentage of patients with a report or a record review as evidence. Elective criteria in the same cluster credit the practice for educating patients about new prescriptions and for assessing medication response and barriers to adherence.
The threshold changed this year. Under the 2017 edition, both criteria were met at more than 80 percent. NCQA's Standards and Guidelines Version 11.1, effective January 1, 2026, raised both to more than 90 percent. Practices that were comfortably passing at 85 percent now need a tighter process, and practices in annual reporting this year should run the report before submitting rather than assuming last year's number holds. Late fees for annual reporting also began on January 1, 2026, so the report needs to exist on time.
Two other places in the standards depend on this work. The Care Coordination and Care Transitions concept requires the practice to identify patients with unplanned admissions and ED visits and to contact them after discharge; that contact is the natural trigger for KM 14. And the Care Management and Support concept requires a person-centered care plan for patients in care management (CM 04, core); in practice the reconciled medication list is the backbone of that plan, because nearly every goal in it involves a medication.
Who does what
The practices we see struggle with reconciliation usually assign it to one role, either the medical assistant (who lacks the clinical authority to resolve differences) or the physician (who lacks the time to collect the sources). The workflow below splits it into collect, compare, reconcile and sign, with a different person responsible for each.
| Step | Who | When | What is produced |
|---|---|---|---|
| 1. Identify the transition | Care coordinator or front desk | Daily, from ADT feeds, hospital discharge summaries, ED reports and patient calls | A transition list with discharge date and 30-day deadline |
| 2. Collect the sources | Medical assistant or care coordinator | Before the visit or during the post-discharge call | Discharge medication list, pharmacy fill history, the patient's own bottles or list |
| 3. Compare line by line | Medical assistant, using a template | At rooming or on the call | A discrepancy list: new, stopped, dose changed, duplicate, patient not taking as prescribed |
| 4. Reconcile | RN, clinical pharmacist or the clinician | During the visit or within 2 business days of a telephone reconciliation | A decision for each discrepancy, entered in the medication list |
| 5. Sign and communicate | Clinician | Same day | Signed reconciled list, a copy to the patient, and a note documenting the reconciliation |
Step 3 is the one to invest in. Give the medical assistant a script that does not ask "any changes?" but instead reads each medication back and asks how the patient takes it, then asks the three catch-all questions: anything new from the hospital or another doctor, anything you stopped or ran out of, anything over the counter, herbal or from someone else's cabinet. Over-the-counter medications and supplements belong on the list; NCQA expects them there, and they are where the NSAID in our opening example would have surfaced.
Step 4 is where clinical judgment lives. A nurse can resolve "patient stopped the statin because of leg pain" as a flag for the clinician; only the clinician decides whether to restart, switch or stop. If the practice has access to a clinical pharmacist, even a few hours a week, this step is where the time goes.
What the note must contain
An EHR checkbox that says "medications reconciled" is not evidence, either for NCQA or for a Medicare auditor reviewing a TCM claim. The note, or the structured reconciliation record, should show four things: which sources were compared (for example "hospital discharge summary dated May 12, pharmacy fill history, patient's bottles"), each discrepancy found, the action taken on each, and the name, credential and date of the person who reconciled. Then the medication list itself should be updated so that the next person who opens the chart sees the current regimen, with the stopped medications marked as discontinued and dated rather than deleted.
A reconciled entry for our opening patient would read: discharge summary lists metoprolol succinate 25 mg daily (new; added to list), furosemide 40 mg daily (previously 20 mg; dose updated), naproxen (discontinued at discharge; patient still taking; instructed to stop and counseled on acetaminophen); reconciled by the RN, reviewed and signed by the physician on the visit date. That entry takes two minutes to write and answers every question a reviewer could ask.
Give the patient the result. A printed or portal copy of the reconciled list, in plain language, is part of the workflow, not an extra. Patients who leave with a list that matches the chart are less likely to be the source of the next discrepancy.
The billing that rides on the same work
Medicare's transitional care management codes pay for the 30 days after a discharge: 99495 requires an interactive contact within two business days of discharge and a face-to-face visit within 14 days with moderate complexity decision making; 99496 requires the visit within 7 days with high complexity. Both require medication reconciliation and management to be completed no later than the date of the face-to-face visit. The workflow above, run from the transition list, produces exactly the documentation those codes need. Practices that already do the reconciliation and do not bill TCM are leaving the payment for the work on the table; practices that bill TCM without a documented reconciliation are at risk on review.
The CPT Category II code 1111F (discharge medications reconciled with the current medication list in the outpatient record) is how the post-discharge reconciliation is reported for quality measures, including the medication reconciliation component of the HEDIS Transitions of Care measure and MIPS quality measure 046, both of which look for reconciliation within 30 days of discharge. It carries no payment by itself, but reporting it lets the payer see the work, and for practices in Medicare Advantage quality arrangements that visibility affects the year-end payment. Add 1111F to the TCM visit or to whatever visit the reconciliation happened at, whenever it was completed inside the 30 days.
The numbers to watch
Three reports, run monthly, tell you whether the workflow is working. First, the KM 14 measure: of patients with a known transition in the month, the percentage with a documented reconciliation within 30 days of discharge. Second, the KM 15 measure: of patients seen in the month, the percentage whose medication list was reviewed and marked current at the visit. Third, the discrepancy rate: of reconciliations performed, the percentage that found at least one difference. That third number is the honesty check. Published studies reviewed by AHRQ have consistently found discrepancies in a large share of patients at care transitions, so a practice reporting a discrepancy rate near zero is almost certainly clicking a box rather than comparing lists.
The denominator is where practices lose points. If your transition list only includes patients who happen to mention a hospital stay, the KM 14 percentage looks fine and the process is missing most of the transitions. Get the admission, discharge and transfer (ADT) notifications from your hospitals, through the state health information exchange or the hospital's own feed, and build the transition list from that.
Questions we hear
Does a telephone reconciliation count for KM 14?
Yes, if it is a real reconciliation: the sources are compared, discrepancies are resolved by someone with the authority to do so and the outcome is documented in the medication list. Many practices do the collection and comparison on the two-business-day TCM call and finish the clinical reconciliation at the visit. Document both parts and date them.
Our EHR has a "reconcile" button that imports the discharge list. Is that enough?
The import is step 2. Someone still has to compare the imported list against what the patient is actually taking and decide each difference. Use the button to save typing, then complete steps 3 through 5 and write the note. An imported list that was never confirmed with the patient is a new source of error, not a reconciliation.
How do we handle patients who see four specialists who all change medications?
Treat each specialist visit that changes therapy as a transition. Ask the specialists' offices for their visit notes (most send them automatically to the primary care physician of record), review the medication section on receipt, and reconcile at the next contact. For the highest-risk patients, a scheduled quarterly reconciliation call by the nurse or pharmacist is cheaper than the admission it prevents, and it also feeds the care plan under CM 04.
What to do this week
- Run the KM 14 and KM 15 reports as your EHR currently produces them and read ten of the "reconciled" charts to see whether the note shows a comparison or a checkbox.
- Write the medical assistant script for collecting the list, with the read-back and the three catch-all questions, and pilot it in one clinician's schedule.
- Build the daily transition list from ADT notifications or discharge summaries, with a 30-day deadline column.
- Add a reconciliation note template with the four required elements: sources, discrepancies, actions, signer and date.
- Check whether every documented post-discharge reconciliation in the last quarter had a TCM code or 1111F attached, and fix the charge capture where it did not.
