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. 

About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

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