WhenitcomestoriskadjustmentandHierarchicalConditionCategory(HCC), properdocumentationandcodingareallthatstandbetweenahealthcare organizationandthepotentiallossofmillionsofdollarswhentheOfficeofthe InspectorGeneral(OIG)comescalling.Anumberofhealthplanshavelearned thisthehardway,withOIGinvestigationsnettingclawbacksashighas$54.3 millionfromSCANHealthPlanand$34.4millionfromHumanaChoice (administeredbyHumana,Inc.)duetonon-compliancewithrisk-adjusted programs.
AswediscussedinarecentFortheRecordarticle,DocumentationDilemmas: DoesYourDocumentationMeettheMEATCriteria?,ICD-10-CMCoding Guidelinesstatethatalldocumentedconditionscoexistingatthetimeofan encounterthatrequireoraffectpatientcaretreatmentormanagementmust becodedasadiagnosis.Assuch,physiciansmustclearlyandprecisely documenteachdiagnosisbasedonclinicalmedicalrecorddocumentation fromaface-to-faceencounter–whichmeansthatdiagnosescannotbe completelydeterminedfromtestresultsandapatient’spastmedicalhistory.
Meet MEAT
Toensurethisisthecase,manyorganizationsusethe“MEAT”criteriafor theirdocumentationpracticesalongwithHierarchicalConditionCategory
(HCC)assignmentsandICD-10-CMdiagnosiscoding.MEATstandsforthefour factorsthatestablishthepresenceofadiagnosisduringaface-to-facepatient encounterandensureproperdocumentation:
• Monitor forsigns,symptoms,diseaseprogression,anddisease regression
• Evaluate viatestresults,medicationeffectiveness,responseto treatment,andphysicalexamfindings
• Assess/Address throughdiscussion,recordsreview,counseling, acknowledging,and/ordocumentingthestatus/levelofcondition
• Treat withmedications,surgery,orothertherapeuticintervention, refertoaspecialistand/orplanforongoingmanagemen
CodersusetheMEATformuladuringriskadjustmentdocumentationand codingtohelpthemcorrectlyidentifyandassignHCCchroniccondition diagnoses,whichpayersalsousetoaccountfortheoverallhealthandmedical costexpectationsofeachpatientenrolledinahealthplan
Leveraging MEAT
Accurateandcompletedocumentationofchronicconditiondiagnosesisan essentialcomponentoftheriskadjustmentandHCCprocess.Leveragingthe MEATcriteriahelpsensurethatprovidersproperlydocumentallconditions evaluatedduringeveryface‐to‐facevisit.TosupportanHCC,documentation mustsupportthepresenceofthedisease/conditionandincludetheclinician’s assessmentand/orcaremanagementplan.
Thisiswherethingsgettricky.Simplylistingeverydiagnosisinthemedical recorddoesn’tsupportareportedHCCcode.TheCentersforMedicareand Medicaid(CMS)focusesonthesediagnosestodemonstratetheneedfor higherreimbursementratesforpatientswhohavemoreseriousconditionsor problemstomanage.Assuch,ifthediagnosisontheclaimisinaccurateor incomplete,theresultcouldbealowerreimbursementrate.
Toavoidthis,codersmustreviewtheentiremedicalrecordtoensuretheyare assigningtheappropriateICD-10-CMdiagnosiscodes.Forexample,the
reviewoftheproblemlistshouldshowevaluationandtreatmentforeach conditionthatrelatestoanICDcode.Thiscouldincludedocumentationsuch as“diabetes(E11.9)remainsstable,willcontinueinsulin10unitsdaily"or "patienthaspanictypeanxiety(F41.0)andthepatientcomplainsthatbreak throughpanicattackshaveincreased.WilladdBuspirone15mgtabletsonce dailytomedicationregimen."
Additionally,providersshouldshowevaluationandtreatmentforall conditionsassessedduringtheencounteraswellasensurethatthe informationisthoroughlydocumented,forexamplebyincluding“historyof” conditionsthataffectthecurrenttreatmentplan.Forexample,ifthereisa historyofcoloncancer(Z85.038)andthepatientisorderedtohavea screeningcolonoscopy,besuretoincludethisinformationundertheA/P.
Avoid Rejection
MEATcriteriaareatthecruxofriskadjustment.Documentationforavalid diagnosismustprovideevidenceofhowtheconditionismonitored, evaluated,assessed,ortreatedforittobecapturedforriskadjustment.As such,providersshould:
• Documentallconditionsevaluatedduringeachencounter
• EnsureaproperprogressnotewiththeHPI,physicalexam,andmedical decision-makingprocess
• Documenteachdiagnosisinanassessmentandcareplan
• Ensurethateachdiagnosisprovidesevidencethattheprovideris Monitoring,Evaluating,Assessing/addressing,andTreatingthe condition.
ByleveragingMEATcriteriatosubstantiatethediagnosis,thelikelihoodof CMSrejectingthediagnosisduetolackofevidencebytheprovideris substantiallyreduced.
Source of content: AGSHealth Blog - Documenting to Meet MEAT