Talking HCCs: Baseline Documentation Requirements for your Records

by Rose T. Dunn, MBA, RHIA, CPA, FACHE and Laurie M. Johnson, MS, RHIA, FAHIMA    

Join us for a discussion of HCCs by two industry leaders: Rose T. Dunn, MBA, RHIA, CPA, FACHE, and Laurie M. Johnson, MS, RHIA, FAHIMA.      




RoseSo, Laurie, the last time we spoke, we talked about the synergies between documentation and coding and how the combination of good documentation and coding could optimize the risk adjustment factor (RAF). (I think that “optimize” is still an ok word to use without it being considered an ‘inappropriate’ activity.) But, in light of enhanced coding, there’s still external oversight. How are your clients preparing for external reviews?        


LaurieWe advise clients that clinical documentation is very important to support the HCCs as well as the RAF. The clinical documentation must clearly reflect the patient’s condition and experience. It is imperative to spend some time in educating physicians and extenders regarding the theory behind HCCs. This education typically involves providing documentation tips regarding their most frequent conditions to ensure specificity is documented.          


RoseI find the Coders Guidance provided by CMS for the Risk Adjustment Data Validation (RADV) auditors to be fairly comprehensive. (See: Coders Guidance.) It’s too bad that there hasn’t been much from CMS in terms of an update from this September 2017 guidance. When we use this with our clients, we make sure to incorporate any coding guideline changes made by the Cooperating Parties and Coding Clinic advice since that date. I think we can glean some good points from the CMS guidance to do a quick review of our records to ensure that critical documentation elements are included:

  • Medical record documentation must be legible
  • For risk adjustment data validation purposes, CMS will only consider medical record documentation from a face-to-face encounter
  • CMS does not accept initials and a date on a lab report as adequate documentation
  • Physician’s signature and credentials must be included on each patient encounter
  • Electronic Signature requires authentication by the responsible provider (for example, “Approved by”; “Signed by”; or “Electronically signed by”)
  • Patient’s name must appear on every page of the medical record and all entries/encounters must be dated

Any suggestions how a practice should ensure these minimal documentation elements are present, Laurie?        


LaurieRose, it has been reported that over 90% of the physician practices are currently using an electronic medical record. The electronic medical record can be set to ensure that these key elements are included in the documentation in order to be in compliance with the RADV requirements. The easiest time to make these data elements required is at implementation but it can be certainly be added afterwards as well. As we move to telehealth, and face-to-face encounters become virtual, it will be even more important for the clinical documentation to be clear regarding the service provided, what the discussion included, and having the physician sign-off and date the visit findings. While I haven’t seen yet if telehealth notes can be used for RADV, it would be good to be pro-active. Medicare has stated that they are supporting telehealth and will begin to pay for it. If our readers are interested, here is the website to read more about Risk Adjustment. Rose, have a great week!      


Fundamentals of HCC Coding  Go beyond just the diagnoses — really understand the methodology behind HCCs! Learn how from nationally recognized HCC expert, Rose T. Dunn, MBA, RHIA, CPA, FACHE.




Rose T. Dunn, MBA, RHIA, CPA, FACHE Rose Dunn is the Chief Operating Officer of First Class Solutions, Inc., a healthcare information management leader since 1988, offering professional consulting services in health information management operations and information governance issues, as well as coding support, coding quality reviews, privacy/security guidance, temporary (interim) management, revenue cycle oversight, and accreditation preparation.  Rose is the author of Libman Education’s online course: Fundamentals of HCC Coding as well as “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on coding management and auditing. Ms. Dunn holds a B.S. and M.B.A. from Saint Louis University.Contact Rose at 314-209-7800 or [email protected]      


Laurie M. Johnson, MS, RHIA, FAHIMA Laurie M. Johnson is a senior consultant at Revenue Cycle Solutions, LLC, a revenue cycle consulting firm specializing in revenue cycle assessments and work plan implementation; interim management with focus on process improvement; and revenue cycle education for hospitals and physician practices. Laurie is a past president of PHIMA and author of clinical coding articles for Journal of AHIMA and ICD-10 Monitor.

About the Author

Libman Education
Libman Education Inc. is a leading provider of training for the health care workforce offering self-paced and instructor-led online courses designed and developed by leading industry experts in Health Information Management (HIM) and Medical Record Coding. Our courses are specifically designed to improve individual skills and increase the efficiencies and competencies of health care providers and institutions. At Libman Education, we understand the needs and challenges of a well-trained workforce and offer the right-mix of online education to ensure that the health care professionals are prepared to meet the challenges of the changing workplace.

3 thoughts on “Talking HCCs: Baseline Documentation Requirements for your Records

  1. Elizabeth Rehmann - June 12, 2019 at 3:17 pm

    Is the On-Line Course available in Hard Print to purchase?

    • Libman Education - June 13, 2019 at 10:42 pm

      Hi Elizabeth,
      Thanks for the inquiry. Our course, Fundamentals of HCC Coding, is an online course. So, technically, it is not in hard print; however, it is self-paced, and you can refer to it as often as you like during the period that you have access to the course.

      Hope this helps! Let us know if we can be of any further help.

  2. Kristin Rodriguez - June 19, 2019 at 11:04 pm

    CMS issued new coders advice in March 2019. I think knowing both of these documents is almost as important as the actual guidelines themselves.