Documentation and Coding – Provider Reference Guide.

How often do I need to document a patient’s condition?

Patient conditions must be managed, evaluated, assessed or treated at least annually, and they must be supported by documentation and submitted diagnosis codes. Documentation must occur at this frequency because CMS redetermines a patient’s risk score each calendar year. Diseases and conditions “disappear” on Jan. 1 of each year and must be re-recorded so the patient’s risk score accurately reflects the presence of these conditions. If a condition is not documented and coded, CMS does not consider the patient to have the condition (including chronic conditions, amputations and ostomy sites) for the current year.

What is each condition worth?

Each condition that impacts risk adjustment (and, hence, payment for a patient’s care) has a unique weight, which is based on the amount of resources needed to manage the condition.

For an at-a-glance resource to determine which conditions impact risk adjustment, please refer to the Diseases and Conditions Associated with HCCs reference card. This document provides a list of some conditions that map to HCCs. Contact your Peoples Health representative for the card, or access it on Provider Portal, under the Resources tab.

Are there special requirements for medical record documentation?

There are no special requirements, but documentation must meet certain criteria to support coding guidelines, which translates to accurate risk scores:

It must be legible to any reader.
It must use only standard abbreviations to ensure clear understanding. Use of symbols (e.g., ↑) is discouraged because symbols cannot support coding—they are indicators, not explicit diagnoses.
It must clearly and explicitly document the conditions evaluated, the assessment (e.g., new, stable or worsening) and the plan of care (e.g., tests ordered, referrals made, patient instructions and schedule recommendation for the next appointment). Diagnoses should be clearly noted and described; simply writing a diagnosis code in the documentation cannot support coding for the condition. You should also explicitly state any causal relationships you identify (e.g., documenting renal failure caused by diabetes as “diabetic renal failure”). Causal relationships may not be assumed. The most common documentation method is the SOAP format (Subjective, Objective, Assessment, Plan).
Each page of documentation (front and back if using a paper medical record) must indicate the patient’s name, identifying information (such as date of birth or member number) and the date of the service (including the month, day and year).
The doctor’s signature or initials, along with credentials, must also be on the documentation. As long as these criteria are followed, the doctor’s credentials and signature or initials are required only once, on the last page of the documentation for the visit. For electronic medical records, electronic signatures must be password-protected and authenticated.

Can I include radiology or lab reports or results as part of my documentation?

You can include radiology or lab reports or results as part of your documentation; however, simply including the report is not sufficient to support coding for a diagnosis. To code, you should document in the medical record the results from the test, your interpretation of the test’s clinical significance (diagnosis) and the corresponding plan of care.

Can I include medication lists as part of my documentation?

You can include medication lists as part of your documentation; however, simply including the list is not sufficient to support coding. The documentation must show an evaluation and assessment of the patient’s condition in response to treatment with the medication and the plan of care for the continued use of the medication (or reason for discontinuing the medication).

Are there special requirements for coding?

There are no special requirements. You should continue to follow the ICD-10-CM Official Guidelines for Coding and Reporting as set forth by CMS, the Department of Health and Hospitals, and the American Medical Association. Codes may not be submitted for any diagnoses that are not explicitly indicated in the medical record documentation. There are a few things to keep in mind about coding:

Code all documented conditions that co-exist at the time of the visit and that you manage, evaluate, assess or treat. Code to the highest degree of certainty any signs, symptoms, abnormal test results or other reasons for the visit.
Diagnose and code to the highest level of specificity. For example, is it bronchitis or chronic bronchitis? The higher level of specificity on the diagnosis will lead you to the correct code. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of any or all of the 4th, 5th and 6th characters. Digits 4 through 6 provide greater detail of etiology, anatomical site and severity.
Do not code as “active” conditions that were previously treated and no longer exist. However, history codes in the ICD-10-CM “Z” category may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
Only code confirmed diagnoses. Do not code conditions documented as “probable,” “suspected,” “questionable,” “rule out” or “working diagnosis.”

Remember: Always document and code to the highest level of specificity using ICD-10-CM codes. This coding system is the current basis of determining risk-adjusted payments.

Note: Some categories, such as diabetes, have a hierarchy in which only the severest level of the illness will “count.”

ICD-10-CM guidelines may require combining two or more conditions into one code. Only use a combination code if it fully describes the patient’s condition.

When the terms “code also,” “code first” or “use additional code” are included in the ICD-10-CM guidelines for a particular code, follow the instructions to fully code the patient’s condition.

I am a specialist. Does risk adjustment apply to me? Should I document and code for conditions I am aware of but that I do not treat as part of my specialty?

It is important for both primary care and specialty physicians to document and code conditions that affect management of the patient’s treatment plan. Diagnoses for many different conditions and body systems factor into a patient’s risk score, which means specialty physicians play an important role in providing accurate documentation and coding for risk adjustment. You should assess, document and code the patient’s primary reason for the visit, as well as all documented conditions that exist at the time of the visit and affect the patient’s care, treatment or proposed treatment, or care management.

In general, it is important to remember that chronic conditions, acute conditions, comorbidities, and acute or pertinent past conditions should be managed, evaluated, assessed or treated at least annually and be supported by documentation and submitted diagnosis codes.

Accurate coding:
Ensures that our plan members are cared for and referred to an appropriate Peoples Health resource to help them manage their health.	Ensures Peoples Health has sufficient dollars to provide supplemental benefits not offered by Original Medicare.