In Part 1 of this blog, we reviewed the role of specialty providers in risk adjusted payments and their diagnoses of conditions that may fall under the CMS-HCC model. In this installment, we’ll evaluate the substance of those consultation notes.
As we all know, an important section of the SOAP note for MRA is the assessment; this is the section where the provider synthesizes all the information he or she collects into a diagnosis for the patient. Sometimes this process is detailed in the assessment and other times, it’s sprinkled throughout the note from sections such as the history of present illness, review of systems, examination and treatment plan. The important thing is that the bread-crumbs that led to a diagnosis are contained in the consultation note along with a plan for treating the patient.
However, many specialist notes include other medical conditions, presumably gleaned from the patient/historian or from the PCP’s note sent to convey the patient’s medical history. Let’s dust off our rheumatologist example from Part 1. In this scenario, the PCP sent her last visit note along with the referral where she explains to the rheum the reason for the referral and her work-up to that point. The patient has a history of diabetes, cardiomyopathy and emphysema.
It’s not uncommon to find non-rheumatological conditions listed in the specialist assessment. As a reminder, items listed in the assessment must have been assessed during the visit and so unless the rheumatologist evaluated the patient’s diabetes, cardiomyopathy and emphysema during the appointment, these conditions have no place on a rheum consult note. The only exception to this is for conditions that impact the condition being treated.
For example, if one of the non-rheum diagnoses impacts, or is being considered in, the rheum’s assessment and treatment – say, prescribing high dose steroids in an uncontrolled diabetic – then it should be included in the note and assessed. This means it can’t merely be listed, but the reason for including the condition in the rheum assessment must be clear. Going back to our scenario, if the rheumatologist is recommending more frequent laboratory tests to monitor the patient’s diabetes, or a diabetes medication change for the patient, these would “tie in” the non-rheum condition to the rheum visit. Similarly, if the existence of diabetes poses a treatment risk or affects the rheum condition, this constitutes a valid link to support diabetes being listed in the assessment, as long as this reasoning is documented. We can’t consider an instance where cardiomyopathy or emphysema would be part of a rheum assessment and so, those conditions should not be documented by the specialist because he or she is not treating them.
Finally, just as important, specialists must take care not to report on their claims ICD-10-CM codes for conditions they are not evaluating at the visit. This habit incorrectly inflates the patient’s risk score and the plan’s/PCP’s funding and exposes them to the liability of a retroactive recoupment.
Join us for Part 3 where we wrap up our blog series by addressing the topic of specialty notes from the perspective of MRA Dept. staff.