Learn more about hierarchical condition categories and how they can help predict the cost of high-risk patients. Kelly Long is a clinical development analyst with 3M Health Information Systems.
For example: If there is a history of breast cancer (Z85.3) and the patient is ordered a mammogram, be sure to include this information under the A/P.įollowing these standard practices will ensure accurate documentation, quality patient care and an improvement in data integrity. There are multiple instances where these conditions are addressed and treated, but do not make it to the Assessment and Plan. It is acceptable to include “history of” conditions if it affects the current treatment plan. However, not only should providers show evaluation and treatment for all conditions assessed at the time of the encounter, but they should also ensure that this information is documented. If the diagnosis on the claim is not accurate or complete, this would indicate that the provider did much less work (medical decision making, evaluation, and management) than actually performed, leading to much lower reimbursement. Hypertension (I10) remains stable, will continue with Losartan 100 mg daily.ĭepression recurrent moderate (F33.1) patient has not noticed improvement on current medication, will increase Zoloft from 50mg to 100mg.ĬMS focuses on these diagnoses to demonstrate the need for higher reimbursement rates for patients who have more serious conditions or problems to manage. An acceptable problem list must show evaluation and treatment for each condition that relates to an ICD code. Simply listing every diagnosis in the medical record does not support a reported HCC code* and is unacceptable according to CMS. These four factors help providers establish the presence of a diagnosis during an encounter and ensure proper documentation. T: Treat-medications, therapies, other modalities
M: Monitor-signs, symptoms, disease progression, disease regressionĮ: Evaluate-test results, medication effectiveness, response to treatmentĪ: Assess/Address-ordering tests, discussion, review records, counseling Each diagnosis must be documented in an assessment and care plan and each diagnosis must show that the provider is Monitoring, Evaluating, Assessing/addressing or Treating the condition: This simply means that diagnoses cannot be wholly determined from test results and a patient’s past medical history.Ī well-documented progress note would include the HPI, ROS, physical exam and show the medical decision-making process. Physicians must accurately document each patient diagnosis and the diagnosis MUST be based on clinical medical record documentation from a face-to-face encounter. The Official ICD Coding Guidelines state that a condition must be present at the time of the encounter, affect patient care or management and be clearly documented in order to be coded as a diagnosis. 21, 2018 / By Kelly Long, BS, CPC, CPCO, CAPM
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