Measure 130: Documentation and Verification of Current Medications in the Medical Record (SOAP 2.0)

This is a guide for 2.0 measure reporting. For 1.0 measure reporting, click here.

Prescription medication use is common among adults of all ages, particularly older adults and adults with chronic conditions. On average, 81% of adults in the U.S. are taking at least one medication (prescription or nonprescription, vitamin/mineral, herbal/natural supplement); 29% are taking five or more.  While these agents may provide some relief, they also may influence physical, mental, and emotional performance. We particularly worry about the impact on activity tolerance, clarity of thought and understanding, self-sufficiency, and motivation. This is a high priority measure and is eligible for one additional bonus point when reported with another high priority measure. 

Note: This measure has been classified as topped out and is capped at 7 points. 

Who can report this measure?

PTs, OTs, and SLPs are all eligible to report on this measure.

Patient Qualifications

  • Patient age (18 or older)
  • Visit type (All)

When do I report on this measure?

Every visit, when an eligible CPT code is billed. There is no diagnosis code associated with this measure. 

Eligible Procedure Codes

PT: 97161, 97162, 97163, 97164

OT: 97165, 97166, 97167, 97168

SLP: 92521, 92522, 92523

Measure Requirements

Document all known medications on the Subjective section. 

For each medication, include:

  • The medications’ name (e.g., Ibuprofen, Zetia, Vitamin D, St. John’s Wort, etc.)
  • Dosage (e.g., 25 mg)
  • Frequency (e.g., 2x daily)
  • Route of administration (e.g., oral, injection, sublingual, etc.)

Measure Specification

For more information on Measure 130, please see the Measure Specification Guide.

Measure Reporting in the WebPT EMR

  1. Click the MIPS badge in the Case Summary to view the current Measure Status. Here you will see all measures that the patient is eligible for based on their Diagnoses and Procedure Code.
  2. On the Subjective section, select the Current Medications subsection to view and edit the required fields for Measure 130.
  3. If there are no known medications, select the No Known Medications checkbox. 
  4. Click the Medications+ link to add the patient’s current medications. 
  5. Measure Met: Enter the Medication Type and Name to satisfy measure requirements. This triggers a Measure Met indicator in the Measure Status column.
  6. When finished documenting, validate the selection in the Measure Status column.
  7. Excluded: Select the Excluded radio button if the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status. Then select the Reason from the drop-down menu.
  8. Not Met: Select the Not Met radio button if the current list of medications are not documented as obtained, updated, or reviewed by the eligible clinician, reason not given.
  9. If the note is signed without completing the required fields, an alert will appear. Required fields must be completed before submitting the note.