Q&A: Acceptable documentation for HCCs
Q: Can you explain where in the clinical documentation it would be acceptable to report from for Hierarchical Condition Category (HCC) purposes? Would you code from history of present illness, past medical history, active problem list, or the assessment?
A: Follow the coding guidelines when reporting diagnosis codes for HCC purposes. The coding guidelines don't change with HCCs. As long as the documentation meets the MEAT (monitored, evaluated, assessed, treated) criteria, it can be reported from anywhere in the note.
“Monitored” could be things such as signs or symptoms or disease progression or regression in the notes. For “evaluated,” look at whether there were test results. Is there some statement regarding medication efficacy or treatment response? “Assessed” is for whether there are any tests, discussion, review of records, or counseling. “Treated” is any note about medication, therapy, surgery, or any other modality addressing treatment of the condition. Only one element of MEAT is required, but the more elements included in the documentation, the better.
You might see documentation differ between providers, but as long as it meets the MEAT criteria or the TAMPER (treatment, assessment, monitor, plan, evaluate, and referral) criteria, a condition can be coded from anywhere in the note—except for the problem list.
Do not code off the problem list unless it is specifically addressed in the note. This list often isn't updated. It could have been imported as part of a template, but it won't necessarily meet the MEAT or TAMPER criteria.
Editor’s Note: Shea Lunt, RHIA, CPC, CPMA, PMP, a consultant for Haugen Consulting Group, answered this question during the HCPro webinar, “HCCs: Physician Practice Coding and Documentation Strategies for Success.” This answer was provided based on limited information. Be sure to review all documentation specific to your individual scenario before determining appropriate action.
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