Which Documentation Can We Use for HCC Coding?
by Rose T. Dunn, MBA, RHIA, CPA, FACHE
Coding professionals may code conditions that are addressed by an acceptable provider and found in the History of Present Illness (HPI), Physician Examination (PE), Assessment, Impression, and/or Plan.
However, “MEAT” will continue to apply to these conditions. That is, the condition must be: “Measured or Monitored,” “Evaluated,” “Assessed or Addressed,” and/or “Treated.”
JustCoding (3/19/14) offered these additional elements:
- 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
So, what should the coding professional do when they see a condition in the problem list or a medication being ordered for a condition that doesn’t appear in the HPI, PE, Assessment or Plan?
This is a provider educational opportunity! Take advantage of this opportunity to query and speak with the provider.
What are you doing to ensure your documentation is sufficient? I’m hopeful that physician practice coders are querying their providers to enhance the clarity and completeness of documentation in the practice records.
Introduction to HCC Coding
Complete and accurate coding for Hierarchical Condition Categories (HCCs) presents an opportunity for improved data quality and appropriate reimbursement. Learn how from nationally recognized HCC expert, Rose T. Dunn, MBA, RHIA, CPA, FACHE.
