Good Documentation - Unacceptable Types of Diagnoses (outpatient hospital and physician settings):

[Holly Cassano]

It Starts With Documentation

Good documentation begins with the patient’s face-to-face encounter with the provider. The medical record is used to determine ICD-9-CM codes. The pertinent information from the patient encounter is submitted to the MA organization for payment. The diagnosis must be based on clinical medical record documentation from the face-to-face encounter.

CMS is very specific about how a diagnosis is ascertained and coded for a patient. The following list is of Unacceptable Types of Diagnoses (outpatient hospital and physician settings):

• Probable• Suspected• Questionable• Rule out• Working


CMS is also very specific as to where the source documents may come from in order to utilize the information for Risk Adjustment. The following list is of Unacceptable Sources of Medical Records and Medical Documentation:

• Skilled nursing facility (SNF) (See Additional Guidance)• Alternative data sources (e.g., pharmacy)• Unacceptable physician extenders (e.g., nutritionist)• Superbill• Physician-signed attestation• A list of patient conditions (Problem List)• A diagnostic report that has not been interpreted• Any documentation for dates of service outside the data collection period

 

[Alicia Scott]

I think one of the key ones here that Holly has stated that is tempting is "Problem Lists". Some have said you can pull a dx off a problem list if you can prove via link that it is being treated. One of the most common places is to do this is the medication list.
Thoughts?

 

[Deb McEachern CPC]

Even if the condition is listed in the problem list and has supporting documentation that it is being treated, like the medication list, we cannot pull out an HCC. Example: Problem list: Angina. Medication list: nitro. This is now a "suspect" HCC but cannot be coded. It is up to the Provider to document Angina in Assessment and Plan in order for us to capture that. In the end, we HCC coders can only capture what the Provider documents. We can query the Provider with the "suspect" HCC. But we can't capture and code it. It must meet MEAT guidelines: Monitoring, evaluating, assessing/addressing and treatment.

 

[Kari Heath CPC]

Sometimes problem lists are not current <hanging head in shame> but the statement is true.

 

[samsuddin]

Hello everyone I am also doing crc exam preparation,if documents are proper with acceptable provider than accept for payment if any hcc value is there than..
..if any one have crc exam preparation material or question papers than mail me plzz sbalesaniya1991@yahoo.in

 

[Alicia Scott]

This is true about problem lists. What happens out there that makes this confusing is that some MA plans or companies contracted out to them have different in-house rules/guidelines in what they will accept. As the field grows I feel we will see more definite guidelines. As we keep saying this is the wave of the future and it is our job to educate the providers in what is accepted documentation to capture an HCC. If we are diligent now then there will be no HCC auditor's coming in behind us stating "this" is not accepted.

There should not be but you will find grey areas in HCC coding because of that for a while.

 

[dsunryz]

Hello,

I am currently doing HCC coding for SNF's, I was wondering where I can look at the "additional guidance" you mentioned.

Thank you,
Dawn

It Starts With Documentation

Good documentation begins with the patient’s face-to-face encounter with the provider. The medical record is used to determine ICD-9-CM codes. The pertinent information from the patient encounter is submitted to the MA organization for payment. The diagnosis must be based on clinical medical record documentation from the face-to-face encounter.

CMS is very specific about how a diagnosis is ascertained and coded for a patient. The following list is of Unacceptable Types of Diagnoses (outpatient hospital and physician settings):

• Probable• Suspected• Questionable• Rule out• Working


CMS is also very specific as to where the source documents may come from in order to utilize the information for Risk Adjustment. The following list is of Unacceptable Sources of Medical Records and Medical Documentation:

• Skilled nursing facility (SNF) (See Additional Guidance)• Alternative data sources (e.g., pharmacy)• Unacceptable physician extenders (e.g., nutritionist)• Superbill• Physician-signed attestation• A list of patient conditions (Problem List)• A diagnostic report that has not been interpreted• Any documentation for dates of service outside the data collection period

 

[Carolyn Heath]

Don't you also go to the assessment and plan first to see what the diagnosis is? Then after reading the assessment and plan, go to the beginning of the document and look for other diagnoses. That was what I was told to do when I did HCC Coding a few years back. Maybe it has changed since then.