Examining diagnosis reportability
Regardless of the record format, the provider’s goal should be to accurately document all acute, exacerbated, and/or chronic conditions that required evaluation, diagnostics, monitoring, and/or treatment during the episode of care. A diagnosis can be reported whenever resources (services, supplies, attention, time, and medical judgment) have been expended to care for the patient. The documentation should support the fact that the condition was addressed or considered during the patient’s care.
[The Uniform Hospital Discharge Data Set] has identified criteria that allow conditions to be coded. Documentation must demonstrate that a condition affects patient care by requiring one or more of the following:
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures
- Extended length of hospital stay
- Increased nursing care and/or monitoring
Due to the brevity of outpatient encounters and their associated documentation, reportability can be difficult to determine in the outpatient environment. Coders must consider this carefully when reviewing records.
Many people use acronyms to remind them of what is needed to support the reporting of a diagnosis. Common acronyms for this purpose include MEAT (was the diagnosis Monitored, Evaluated, Assessed, or Treated?) and TAMPER (did the provider Treat, Assess, Monitor, Plan, Evaluate, or Refer related to the diagnosis?).
These acronyms reinforce that a mere statement that a diagnosis is present is not enough; the record must also demonstrate the thought process behind the diagnosis. This thought process may not be clear with a quick review of the record, so coders must look at interventions given by not only the provider but also the ancillary staff, including nurses and therapists.
Providers must draw clear relationships between related diagnoses and speak to the conditions considered in the planning of their care. Their medical decision-making must be evident within their documentation. Many providers fail to include this information, and they must be educated as to why its inclusion is so important.
Editor’s note: This article is an excerpt from the “2026 Just Coding Pocket Guide.” Purchase your copy today to gain insights on diagnostic criteria, official coding guidelines, and documentation requirements.