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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. 



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 jumped into the weeds of ICD-10 more than 10 years before it was implemented and has been getting back into the weeds of HCCs for the last 2 years. 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 is assisting Libman Education in the development of an HCC educational program. Ms. Dunn holds a B.S. and M.B.A. from Saint Louis University. Contact Rose at 314-209-7800 or [email protected]

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.

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