Capture Chronic Conditions in the Outpatient Setting With Confidence - AAPC When reviewing the medical record, coders need to look for evidence that the condition, or its treatment, had an impact on the encounter Was the patient’s hypertension monitored, evaluated, assessed, or treated? Did the provider state its significance to the encounter or show how it affected their medical decision making?
Risk Adjustment Documentation and Diagnosis Coding - AAPC Risk adjustment coders should never suggest what to document solely for risk adjustment purposes; it is a good idea to avoid focusing on risk value examples when reviewing a medical record with the provider, even if risk value was part of the decision to initiate education to the provider
Include MEAT in Your Risk Adjustment Documentation One way to help ensure your documentation is up-to-par for HCC coding is to include MEAT (monitored, evaluated, assessed addressed and treated) in the medical record for the patient encounter To break it down, documentation must reflect: M – Monitoring signs, symptoms, disease progression, disease regression
Overpayments Are an Obligation to Refund - AAPC by John Verhovshek, MA, CPC As part of an active compliance program, your practice should take steps to identify and, where appropriate, return
Wiki Which part of the documentation can Coders use to code from? - AAPC I would disagree with the above - there is no rule or guideline that the diagnosis cannot be taken from the HPI or any other section of the documentation - only that the diagnosis must be documented "by patient's provider (i e , physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis)" as existing or affecting care at the time of the
Kidney Transplant Dx. Coding - AAPC Knowledge Center Use additional code to specify infection Other complications of Kidney transplant T86 19 Gouri Pathare MBBS, CPC, is a practicing medical professional with nearly 30 years of experience as an independent private medical practitioner in Mumbai, India, and has worked as a clinical specialist training coders for Episource India Pvt, Ltd , a United States-based KPO company
Realize the Value of HCC Coding - AAPC Knowledge Center The documentation in the patient’s medical record must support the condition as present and as being assessed and or planned by an eligible provider qualified to manage the condition Use MEAT to Capture Codes One strategy that is commonly used by organizations to capture a diagnosis is the “MEAT” method:
CMS Provides New Guidance for SDOH Risk Assessments An essential point that many providers may overlook is that the SDOH risk assessment is not a screening; it is “intended to be used when a practitioner has reason to believe there are unmet SDOH needs that are interfering with the practitioner’s diagnosis and treatment of a condition or illness,” CMS clarifies in the final rule
ICD-10-CM Code for Cough R05 - AAPC ICD-10-CM Code for Cough R05 ICD-10 code R05 for Cough is a medical classification as listed by WHO under the range - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified