Risk Adjustment Documentation & Coding Improvement Reference Information
In today's quality and patient-centered health care environment, the importance of accurate, specific and thorough medical record documentation and coding has become vital to physicians, other health care professionals and payers to assist in the optimization of clinical outcomes. The information below gives documentation and coding examples for the most common chronic conditions and also provides tips to assist in the accurate and specific capture of each patient's health status in accordance with ICD-10-CM Coding and Reporting guidelines.
Remember, if a condition has been:
Monitored (signs, symptoms, improvement/worsening of condition);
Evaluated (test results, medication effectiveness, response to treatment);
Assessed (ordering tests, review records, counseling) and/or;
Treated (medications, therapies, other treatments/procedures), the condition should be coded and reported on the claim.
Please note: It is not enough to document a condition(s) in a problem list or simply state the condition in the history or physical exam. Condition(s) should be listed in the assessment/plan with support and reported on the claim to accurately capture and code. Accurate and comprehensive reporting of all conditions related to the patients' severity of illness allows a patient to be identified for disease and care management programs that assist with improving their health status.
Reasons to focus on documentation and coding improvement
Identify and clarify documentation that is conflicting, questionable, incomplete or missing in the medical record to facilitate the accurate capture of each patient's level of disease severity.
Support and meet clinical quality initiatives and diagnosis driven program requirements.
Take a proactive approach to improving documentation and coding to be prepared for diagnosis-driven payment models.
Leverage and enhance electronic health record (EHR) technology to assist physicians with thorough documentation and specific coding. Create teams of physicians, nurses, coders and billing staff to champion improved documentation and accurate coding.
Ensure you are able to fully report all diagnoses that were monitored, evaluated, assessed and/or treated during the encounter on a claim. Horizon is able to accept up to 12 diagnoses per outpatient/provider claim.
To assist in the patient's continuity of care, the health care team involved in care management relies on thorough and accurate documentation to make ongoing medical and treatment decisions.
Horizon prepared this summary to assist providers with the Centers for Medicare & Medicaid Services (CMS) coding requirements. Horizon believes the determination of the appropriate diagnosis codes is made by the clinician.
Examples: documentation and coding
The following are examples of assessments/plans for some of the most commonly reported chronic conditions. The scenarios include documentation requirements supporting the condition(s) and ICD-10-CM code(s) as well as tips assisting in accurately and thoroughly recording the condition.
| Diabetes with Hyperglycemia | |
|---|---|
| SOAP Note | Diabetes not controlled, patient unable to keep blood sugar (BS) low enough and is hyperglycemic. Will adjust insulin and see patient for follow up in two weeks. Asked patient to keep log of daily BS during this time. |
| ICD-10-CM Codes |
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| Documentation/ Coding Tips |
To code conditions as being diabetic complications/manifestations, the medical record documentation must present a specific causal relationship between the two conditions. Examples of such a causal relationship include: “with, in related to, related with, diabetic, due to,” etc. Exceptions to the casual relationship rule in ICD-10-CM are any conditions listed under Diabetes, sub term “With”. The following is an excerpt from the ICD-10-CM codebook index (ICD-10-CM Complete Code Set 2017, AAPC). Note: this list is not all-inclusive. Please refer to the most up to date codebook for a complete list.
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| Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation | |
|---|---|
| SOAP Note | Acute exacerbation of COPD with acute bronchitis due to patient smoking. Advised on smoking cessation. Increase prednisone, prescribed antibiotic and increased nebulizer treatments to every two to four hours. Follow up in five days or sooner if symptoms worsen. |
| ICD-10-CM Codes |
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Documentation/ Coding Tips | Four codes are required for the scenarios above:
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| Asthma | |
|---|---|
| SOAP Note | Intermittent asthma with acute exacerbation due to exposure to secondhand smoke. Prescribed three-day course of prednisone and continue albuterol inhaler. Follow up in three days or sooner, if symptoms worsen. |
| ICD-10-CM Codes |
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| Documentation/ Coding Tips | Refer to the National Heart Lung & Blood Institute (NHLBI) for asthma severity guidelines:
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| Body Mass Index (BMI) | |
|---|---|
| SOAP Note | Morbid obesity recorded BMI is 40.2 – patient admits to overeating. Discussed dietary changes and reduced caloric intake at length. Will schedule consult appointment with our registered dietician. Type 2 Diabetes without complications: A1c within normal limits. Continue current medication. |
| ICD-10-CM Codes |
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| Documentation/ Coding Tips |
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| Atrial Fibrillation/Atrial Flutter | |
|---|---|
| SOAP Note | Patient has intermittent episodes of irregular heartbeat over the past year causing shortness of breath. Paroxysmal atrial fibrillation (PAF) recorded on Holter monitor. Patient is also being treated for hypertension. Patient admits to non-compliance with taking medicines. Stressed importance of compliance with patient. Follow up in one week. Patient had Myocardial Infarction (MI) six months ago. |
| ICD-10-CM Codes |
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| Documentation/ Coding Tips | Atrial Fibrillation (AF) is broken down into three categories:
Atrial flutter (AFL) is broken down into two categories:
If sick sinus syndrome or another cardiac arrhythmia has been successfully treated by implantation of a pace-making device (which is not malfunctioning), the arrhythmia diagnosis should not be captured, as it is considered to be a historical condition, which has now been resolved. AF and AFL can specifically be captured when not specified as controlled, resolved or compensated, or when being controlled by medicine as long as that medicine is noted in the visit documentation by the physician or other health care professional. An assessment of the condition, e.g. stable EKG results or Physical Exam findings, may also serve as M.E.A.T. If non-compliance with medication is documented, it should be coded to category (T36-T50) for underdosing (taking less medicine than prescribed by a physician or other health care professional), along with a code from (Z91.12-Z91.13) for non-compliance or complications of care (Y63.6-Y63.9). For encounters occurring while the MI is equal to, or less than, four weeks old, including transfers to another acute setting or a post-acute setting, and the MI meets the definition for “other diagnoses” (see Section III, Reporting Additional Diagnoses, in the ICD-10-CM Codebook), codes from category I21 may continue to be reported. For encounters after the four week time frame and if the patient is still receiving care related to the MI, the appropriate aftercare code should be assigned, rather than a code from category I21. For old or healed MI not requiring further care, code I25.2 – Old MI, may be assigned. |
| Malignant Neoplasm of Breast | |
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| SOAP Note | Estrogen positive Stage II ductal carcinoma lower inner quadrant of the left breast. Completed first round of chemotherapy. Follow up with patient after the next round of chemotherapy and repeat laboratory work. |
| ICD-10-CM Codes |
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| Documentation/ Coding Tips |
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| Secondary Neoplasm of Bone | |
|---|---|
| SOAP Note | Metastatic bone cancer originating from breast cancer. Breast cancer was eradicated four years ago. Doing well with current pain management regimen. Follow up with patient after the next round of radiation. |
| ICD-10-CM Codes |
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| Documentation/ Coding Tips |
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| End Stage Renal Disease (ESRD) with Dialysis Status | |
|---|---|
| SOAP Note | ESRD and hypertension. Glomerular Filtration Rate (GFR) 10-stable since last laboratory workup. Continue with dialysis three days a week. Hypertension is stable on current medications. |
| ICD-10-CM Codes |
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| Documentation/ Coding Tips |
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ECN009671A (0823)