by Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FHFMA
We recently received a question regarding the use of problem lists to support HCC diagnoses:
My question is regarding the documentation source for Inpatient. “Problem Lists’ are not considered a source to get the documentation, is that correct? Is there a website I can go to find this information to share with my Quality Department and Coding Manager? This is an ongoing debate at our facility and I would finally love to have a resolution.
This is a great question and one I am asked regularly. I often refer my clients to the “Risk Adjustment User Group Questions & Answers” published by CMS. While originally answered in 2008, the instruction has not changed. The question of coding from problem lists is discussed:
Q: Is an undated/unsigned problem list acceptable documentation of a diagnosis if the progress notes refer to the list in the medical record?
A: Plans should use the progress notes as documentation to support the diagnosis instead of the problem list. Problem lists can include any and every type of condition for a person regardless of whether the beneficiary received services for the conditions during the data collection period, and are not acceptable stand-alone documentation.
Let’s review the principles of what documentation is required to allow a coder to code a condition for HCC purposes:
1. HCC rules require FACE-TO-FACE encounters. Coding from a problem list when there is no corresponding face-to-face encounter would not be acceptable.
2. Encounter documentation must reference the diagnosis and achieve MEAT requirements. A problem list alone will not do that. To be complete, documentation for HCC Coding must support the MEAT criteria for each condition:
- Monitor – signs, symptoms, disease progression, disease regression
- Evaluate – test results, medication effectiveness, response to treatment
- Assess/Address – ordering tests, discussion, review records, counseling
- Treat – medications, therapies, other modalities
3. Pulling a problem list into the encounter’s documentation that does not specifically address each of the conditions on the list to the extent of MEAT will not suffice.
4. A problem list may reflect conditions that are no longer pertinent or active. Pulling that list into the encounter could lead to erroneous coding.
Readers interested in more information are referred to this link.
Postscript: While at the Revenue Integrity Summit this week, I had a nice conversation with a physician leader of a large practice in Florida. His practice is immersed in HCCs. He said he is experiencing rejected HCCs where the diagnosis documentation is not meeting ALL 4 elements of MEAT even though the acronym is Monitoring, Evaluating, Assessing OR Treating the condition. The Medical Record Reviewer Guidance for the RADV auditors is silent on the acronym. Bottom line: The more MEAT elements that are documented for a condition, the better.
Fundamentals of HCC Coding
Learn more from Rose! Go beyond just the diagnoses — really understand the methodology behind HCCs with the course “Fundamentals of HCC Coding.” Learn more here.