Document ALL Patient Allergies
We cannot overemphasize how important it is to document all your patients’ allergies on their medical records. Especially medications!
This information needs to be readily accessible to all providers who may have access to the patient’s record. This is not always the case, which has come to our attention through a random audit of records. While there were many who did appropriately document allergies, unfortunately there were records that noted “member reported an allergy to statins,” however, a statin was listed as active on the medication list in the record as well.
If an allergy is stated by a patient and after further investigation noted to not actually be an allergy, it should be removed as an allergy on the permanent record.
Documentation of medical reason(s) for not currently being a statin therapy user
G9781: Documentation of medical reason(s) for not currently being a statin therapy user or receiving an order (prescription) for statin therapy (e.g., patients with statin-associated muscle symptoms or an allergy to statin medication therapy, patients who are receiving palliative or hospice care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease (ESRD), or other medical reasons)
Are you documenting to specificity?
If you are documenting depression on a patient, are you taking the time to specify the type, occurrence, and severity with or without psychotic features or symptoms?
If you are documenting a condition which involves laterality, are you specifying the laterality? For example, coding sequela of a CVA, which side is affected? Remember, once the patient is discharged, regardless of the discharge destination, you are coding the sequela if present, no longer an active CVA!
Document the code(s) that most accurately describe the patient’s condition at the time of the visit. The same amount of detail for the HCC code must be well documented in the medical record as is classified in the ICD-10 code.
Utilize current codes that are the most applicable. Pay attention to “Code also” notes and “Combination codes.”
If you have questions or topics you would like to see addressed regarding Risk Adjustment, contact the team directly at riskadjustment@htanc.com.
A Friendly Reminder
Check in with your patients during the office visit on any changes in their ability to cover the cost of their prescriptions. Have they moved, or are they planning to move? Has transportation become a concern? Has the price of groceries exceeded their budget? Please refer members to the number on the back of their health card. We have resources available! We have sent a list of these resources to your office.