We have blogged quite extensively on all things MRA and especially the need for solid documentation. Historically, a provider’s charting improves when the spotlight is shined on it, but old habits are hard to break; we find that, sadly, documentation deteriorates over time, which can result in risk adjusted codes being removed for lack of proper assessment. Below are some timely reminders of common errors we find in the most seasoned of clinicians, working in the risk adjustment world.
- Improper assessment. We’ve linked some blogs on this subject but in a nutshell: refilling meds, ordering lab tests or pasting copious, templated, un-customized, counseling suggestions does not constitute an assessment. Remember the M-E-A-T acronym; document how you’re Monitoring, Evaluating, Assessing/Addressing and Treating each condition.
- Errors with lab-based conditions. Almost every lab-based diagnosis requires two consecutive values, spaced a few months apart, to confirm. Assessing a lab-based condition similarly requires lab data. Charting that a patient’s “GFR is low” is not a real assessment; better to document that the GFR on MMDDYY was 23 as this conveys a status. If your EMR embeds lab reports into the progress note, this can go a long way toward bolstering your assessment. No need to rewrite the values, but do reference them by describing if they’re better, worse, uncontrolled, etc.
- Inactive cancers. Many years ago, a clinician told us that she considers a patient to have cancer forever because it’s lurking somewhere in that patient’s body. Regardless of your personal feelings about cancers, there are very specific coding guidelines. They are: 1) A cancer that is active. By active, we mean that you have a recent test result or confirmation, and the patient is either not a treatment candidate or chooses to forego treatment, you both elect to “watch & wait” before initiating treatment, or the patient is in the process of beginning treatment. 2) Treatment is directed to the active cancer. This means that the patient is undergoing some treatment directed to the actual malignancy. Common treatments are chemotherapy and radiation therapy. 3) There is evidence of a recurrence. This one is clear-cut: you have a biopsy report or other objective evidence that the malignancy has returned. When a patient has had a malignancy removed, and the treatment is to prevent a recurrence, this is not an active cancer; it is coded as a personal history.
- Combo codes. ICD-10-CM has saved us a few coding steps by creating combos of conditions that often occur together. Some common examples are ASHD with angina and diabetes with a manifestation. It’s important to keep in mind that although you report only one ICD-10-CM code, there are actually two conditions involved. This means that you need to assess both of them and document accordingly. When a patient is diagnosed with diabetic polyneuropathy, for example, and the note discusses only the diabetes, your coder should query you (if the note is still open) or change the code to match what you assessed – in this case, only diabetes.
Consider running a report from your EMR or claims system of patients with a cancer diagnosis, for example, and spot-check a few cases to determine whether they have been correctly coded. Remember to process removals for any erroneous codes you find in your review.