Best Practices for Proper Coding

Capturing the patient’s entire health status is more important today than ever. And - it’s a best practice. Communication is vital to the patient receiving the appropriate treatment promptly. Accurate documentation and coding to specificity are keys to a care team being able to allow a smooth transition if the patient should require treatment from a multidisciplinary team. Inadequate or inappropriate coding can result in poor coordination of care.

A reminder of the 4 As:

• Accurate documentation
• Appropriate coding
• Awareness of all chronic conditions (even if these are being treated by a specialist)
• Always open communication among physicians
  
  

Tips for capturing the overall health status of the patient:

• Remember what’s most likely one of the first things you learned in med school, if it’s not documented, it didn’t happen.
• The medical record must have a legible signature including name, date, and credentials.
• To be considered a valid visit, it must either be face-to-face or for the time being during the ongoing COVID-19 pandemic, an asynchronous audio and video appointment is acceptable for risk adjustment per CMS.
• Be sure the diagnoses being billed match the actual medical record documentation.
  
  

Recall the MEAT acronym as a guide when documenting:

• Monitor: Document all signs and symptoms as well as any disease progression or regression
• Evaluate: Response to treatment, medication effectiveness, review, and document test results
• Assess: Address ordering tests, discussion, review records, and counseling
• Treat: Medications, therapies, and other modalities
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Reminders when coding:

• Document a diagnosis as a history of or PMH only when it no longer exists, is not a current condition, or is not being actively treated.
• Maintain accuracy of coding the patient’s condition with accurate documentation.
• An AMI is now considered acute for four weeks from the time of the incident (date of the MI must be known) if the date is not known or it is past the four-week mark it is coded as a history of.
• Reminder: if it’s not documented, it didn’t happen.
• A CVA becomes history upon discharge from the hospital; sequelae, if present, should be documented.
  
  

If you have any questions or comments about correct hierarchical condition category (HCC) coding, or if your office is interested in receiving additional information on HCC coding or HCC overview for staff refresher, please email us at RiskAdjustment@healthteamadvantage.com.