The concept of medical documentation has usually focused on those elements supporting the evaluation and management (E/M) code selection in fee-for-service payment environments; electronic medical records (EMRs) have done a great deal to alleviate the charting burden for these clinicians. However, the documentation requirement for risk adjusted payments (or MRA) takes things to a whole other level: strong support for the condition and its clear assessment on the page or screen.
Let’s begin with the idea that the four corners of the page or screen form the canvas for MRA diagnoses. This means that the information must be contained on the note. Stretching the canvas analogy a little bit, we’d all agree that we judge a work of art from the artist’s rendition. We don’t also look at the population of paint colors to determine if the artist used the most correct ones, nor do we consult other paintings in the artist’s portfolio in order to judge the current work. Each painting stands alone and is interpreted based on the information, if you will, on that one canvas. That’s how we should think of MRA documentation: everything has to be laid out on the progress note.
An auditor or regulator shouldn’t need to consult test results because those should be summarized on the progress note itself. Most EMRs provide a mechanism for including (in perpetuity) all the elements that form the evidence of a condition, so clinicians can chart – one time – the relevant test results (including date, type of test and findings) that support a diagnosis.
Although every part of the SOAP note is necessary, the assessment and plan are the next important sections. We combine them since each EMR varies in allowing for customized comments. The acronym T-E-A-M (sometimes referred to as M-E-A-T) conveys documentation expectations: show how the condition is being Treated, Evaluated, Assessed and Managed. The MEAT acronym is helpful in painting the picture of “meat on the bone” of the diagnosis. Bones alone are not sufficient.
One of the ideas of MRA is that the increased payment balances out the resources used in TEAM-ing risk adjusted diagnoses. Consequently, the payment is not just because the patient has a condition but because the clinician is TEAM-ing it, which must be clearly evident on the note. This is especially important when a PCP defers the management of a condition to a specialist in that field of study. Many PCPs document no M-E-A-T, opting for a cursory, “Followed by [name of specialist or specialty].” If that is the case, and there is no real assessment, the PCP would do better to entrust his/her funding to the specialist in the hope that clinician reports the properly coded and documented condition.
Read more about proper coding and documentation here and here.