The Art of Mastering Coding and Documentation to Improve Risk Management

Illustration: Lee Sauer

Regardless of your role in your organization, you are likely intimately familiar with the administrative burden that accompanies documentation and coding and the crucial role it plays in a practice’s success. Because the process is complex and can be frustrating, mastering the art of documentation and coding requires “lifelong learning” and a team effort by all stakeholders.

In our fee-for-service and work relative value unit (wRVU)-driven worlds, physicians are paid by payors based on the associated CPT codes billed on the claim. The focus on diagnosis coding has been merely to support medical necessity for the services provided for reimbursement. Revenue, compensation and compliance in physician practices focuses on visit and procedural codes only. Aligning current payment-focused billing and documentation practices with evolving risk-adjustment coding, which focuses on diagnosis, will only become more important for all settings.

A shift towards providing more specific, complete documentation and ICD-10 CM diagnosis codes for all applicable conditions on an annual basis will be a challenge. Failing to adequately capture a patient's risk through documentation and coding may lead to an inaccurately low level of attributed risk and eventually to reduced reimbursement, payment penalties and exclusion from markets. Have you thought about how accurate and thorough documentation and coding can provide the best chance of shared savings and, in turn, help with the successful management of your patient population?

Risk adjustment has become increasingly important under the Merit-Based Incentive Payment System, part of the Quality Payment Program. Physicians must thoroughly report on each patient’s risk adjustment diagnosis and it must be based on clinical medical record documentation from a face-to-face encounter. One important first step is for physicians to improve documentation by understanding MEAT. MEAT is an acronym used in Hierarchical Condition Category to ensure that the most accurate and complete information is being documented.

The next step is to focus on ICD-10 diagnosis code assignment to the highest level of specificity. This includes coding for chronic conditions and coding all documented conditions that coexist at the time of the visit, which require or affect patient care or treatment.

In a world where providers consistently have attempted to meet criteria for levels of care for evaluation and management services and procedures, there is now a new documentation need that further illustrates the complexity of care providers deliver. In the ever-changing environment of healthcare with competing priorities, and the volume of information and technology, we need to understand exactly how our payors evaluate the care we deliver. And perhaps more importantly, we need to know how we will be impacted. The graphic below highlights the importance of documentation and coding.

Documentation and Coding Influence

As healthcare continues to evolve and become more and more complex, physician and administrative leaders need to commit to providing coding and documentation education, training and support to achieve optimum performance.