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By AGS Health
May 18, 2023
When it comes to risk adjustment and Hierarchical Condition Category (HCC), proper documentation and coding are all that stand between a healthcare organization and the potential loss of millions of dollars when the Office of the Inspector General (OIG) comes calling. A number of health plans have learned this the hard way, with OIG investigations netting clawbacks as high as $54.3 million from SCAN Health Plan and $34.4 million from HumanaChoice (administered by Humana, Inc.) due to non-compliance with risk-adjusted programs.
As we discussed in a recent For the Record article, Documentation Dilemmas: Does Your Documentation Meet the MEAT Criteria?, ICD-10-CM Coding Guidelines state that all documented conditions coexisting at the time of an encounter that require or affect patient care treatment or management must be coded as a diagnosis. As such, physicians must clearly and precisely document each diagnosis based on clinical medical record documentation from a face-to-face encounter – which means that diagnoses cannot be completely determined from test results and a patient’s past medical history.
To ensure this is the case, many organizations use the “MEAT” criteria for their documentation practices along with Hierarchical Condition Category (HCC) assignments and ICD-10-CM diagnosis coding. MEAT stands for the four factors that establish the presence of a diagnosis during a face-to-face patient encounter and ensure proper documentation:
Coders use the MEAT formula during risk adjustment documentation and coding to help them correctly identify and assign HCC chronic condition diagnoses, which payers also use to account for the overall health and medical cost expectations of each patient enrolled in a health plan.
Accurate and complete documentation of chronic condition diagnoses is an essential component of the risk adjustment and HCC process. Leveraging the MEAT criteria helps ensure that providers properly document all conditions evaluated during every face‐to‐face visit. To support an HCC, documentation must support the presence of the disease/condition and include the clinician’s assessment and/or care management plan.
This is where things get tricky. Simply listing every diagnosis in the medical record doesn’t support a reported HCC code. The Centers for Medicare and Medicaid (CMS) focuses on these diagnoses to demonstrate the need for higher reimbursement rates for patients who have more serious conditions or problems to manage. As such, if the diagnosis on the claim is inaccurate or incomplete, the result could be a lower reimbursement rate.
To avoid this, coders must review the entire medical record to ensure they are assigning the appropriate ICD-10-CM diagnosis codes. For example, the review of the problem list should show evaluation and treatment for each condition that relates to an ICD code. This could include documentation such as “diabetes (E11.9) remains stable, will continue insulin 10 units daily" or "patient has panic type anxiety (F41.0) and the patient complains that break through panic attacks have increased. Will add Buspirone 15mg tablets once daily to medication regimen."
Additionally, providers should show evaluation and treatment for all conditions assessed during the encounter as well as ensure that the information is thoroughly documented, for example by including “history of” conditions that affect the current treatment plan. For example, if there is a history of colon cancer (Z85.038) and the patient is ordered to have a screening colonoscopy, be sure to include this information under the A/P.
MEAT criteria are at the crux of risk adjustment. Documentation for a valid diagnosis must provide evidence of how the condition is monitored, evaluated, assessed, or treated for it to be captured for risk adjustment. As such, providers should:
By leveraging MEAT criteria to substantiate the diagnosis, the likelihood of CMS rejecting the diagnosis due to lack of evidence by the provider is substantially reduced.
AGS Health is more than a revenue cycle management company–we’re a strategic partner for growth. By blending technologies, services, and expert support, AGS Health partners with leading healthcare organizations across the US to deliver tailored solutions that solve the unique needs and challenges of each provider’s revenue cycle operations. The company leverages the latest advancements in automation, process excellence, security, and problem-solving through the use of technology and analytics–all made possible with college-educated, trained RCM experts. AGS Health employs more than 10,000 team members globally and partners with more than 100 clients across a variety of care settings, specialties, and billing systems.
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