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Meeting CMS documentation requirements for HCC coding

May 18, 2017:

Risk adjustment documentation and coding for accurate CMS Hierarchical Coding Category (HCC) assignment requires the same attention to detail that providers who strive to provide quality care for their patients are accustomed to. The process begins with a face-to-face encounter documented in the medical record. All documented conditions are reported with current ICD-10-CM diagnosis codes, and codes are assigned based on ICD-10-CM Guidelines for Coding and Reporting. All services are reported with HCPCS Level I (CPT®) and II codes. One key component for accurate HCC assignment of Medicare Advantage (MA) beneficiaries and accurate reimbursement for the complexity of care is ensuring that all conditions affecting the health status of the patient are evaluated, documented, coded and submitted to CMS annually.

One of the first things providers must do is to make certain that their MA patients are seen at least annually, which may require patient reminders to ensure that health screenings are scheduled and performed each year. During the annual screening and all follow-up visits, documentation should include the following:

  • Patient name and date on each documentation note
  • Reason for the face-to-face encounter
  • All services rendered
  • A list of all conclusions and findings as well as the need for additional services or follow up
  • Supporting documentation that shows monitoring, evaluation, assessment and/or treatment of each listed condition
  • Authentication of the documentation by the provider of care (signature and credentials)

Next, providers must make sure that the documentation meets the following criteria:

  • Specific: conditions should be documented to the highest level of certainty and specificity at each encounter, including all complications and manifestations of each condition
  • Complete: all confirmed conditions, including those from consultant notes and discharge summaries, should be integrated into the documentation
  • Note: abnormal findings are not reported unless the clinical significance of the abnormal finding is documented by the provider
  • Chronic conditions identified annually: assess and document findings at least once per year
  • All problem pertinent chronic conditions identified on each date of service that the conditions require evaluation, care or treatment

Use the acronym M.E.A.T. to aid in capturing all conditions that should be coded. Any condition that requires monitoring (M), evaluation (E), assessment (A) and treatment (T) should be coded.

More information can be found at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html

CPT is a registered trademark of the American Medical Association.


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