Clinical Documentation Improvement for Optimal Risk Adjustment

Posted on 23 Nov, 2017 |comments_icon 4|By Elizabeth

MACRA obviously has increased the need for CDI in outpatient and clinical settings. MIPS success requires it. Clinical documentation in your HCC coding, including RAF scores, will impact your payment under MACRA.

CDI Fast Facts

  • MACRA has increased the need to consider CDI in outpatient or clinic settings.
  • Your limitations may include a minimally trained or the lack of a coding staff.
  • MIPS will require more accurate, specific and complete diagnosis documentation in the physician clinic setting.
  • Staff will require clinical knowledge and a good understanding of outpatient coding guidelines.
  • You should consider certified coding professionals.

It takes an expert eye when coding for services to pick out key words and provide specific diagnoses to documentation. Your staff will require clinical knowledge and a good understanding of outpatient coding guidelines. Always review your claims to ensure you captured what’s needed.

CDI Checklist

  • Ensure diagnoses are being captured on claims
  • Review current processes for code assignment – ensure proper diagnosis, procedure and E&M ‘Evaluation and Management’ codes are assigned
  • Document and code all active chronic conditions annually
  • Diagnosis capturing HCCs to be performed during a face-to-face encounter – may occur during a patient’s annual physical examination
  • Accurately reflect and report:
  • Acute, chronic, compensated, decompensated, exacerbated
  • If resolved, document it
  • If known, report cause of condition

You might also consider reviewing your current processes for code assignments. Who’s doing it? Are your physicians involved? Is someone assigned to check it? Are all procedures and E/M codes properly assigned?

A diagnosis that maps to a Hierarchical Condition Category (HCC) must be made during a face-to-face encounter. You’ll want to note diagnosis status—e.g., acute, chronic, compensated, decompensated, exacerbated—and likely will need to remind your physician to do so. Take the diagnosis status into account when selecting code specificity. As well, remember to flag all active chronic conditions for ongoing relevance.

When working with physicians, remind them with non-definitive diagnoses to document the signs and symptoms they’re seeing and treating. Remember that “history of” indicates that a condition is no longer under active treatment. Do not use this phrase for chronic conditions.

For example, it’s not enough to write “history of asthma,” even though you later noted a prescription for ProAir. Others may not pick up the ongoing status of the condition. Instead of writing “history of asthma,” write “Asthma since 2012, controlled with ProAir HFA.” If a condition remains a factor of the patient’s health status, it’s not history.

You want to note all pertinent conditions—those that are present but stable, managed on therapy, require some form of observation, require a referral, or affect your medical decision making.

Remember, also, to document the relationship of diagnoses to other conditions. Physicians can do this with simple terminology, employing phrases like: with, due to, caused by, secondary to, etc.

Make sure to keep this information front and center in each patient’s chart and/or EHR. If you work at a small practice that can’t afford EHR, reach out to a larger organization that might be equipped to allocate space, allowing you to piggy back on their EHR. If managed well, this type of partnership serves the greater medical community.

Master Documentation Basics

  • Patient Name, DOB and DOS – every page
  • Use MEAT – a CMS’ HCC mnemonic to help providers and coders capture accurate documentation:
  • MONITORED or managed (signs/symptoms, disease progression/regression)
  • EVALUATED (test review, response to treatment)
  • ASSESSED (tests ordered, record review, counseling, discussion)
  • TREATED (meds, therapies, other modalities)
  • Signature, Credentials, and Date
  • All conditions, including co-Existing conditions that affect treatment or management of a patient
  • Be specific. If a diagnosis is unclear, use signs and symptoms.

Yes, physicians are busy. But if they’re not invested in proper documentation, it will cost them in reimbursement. It also will affect their quality of care and their MIPS score rating, which will impose negative ramifications on their practice.

The big picture review. Include all conditions that affect treatment or management of a patient. Be specific. If a diagnosis is unclear, use signs and symptoms. Document with specificity that captures the entirety of the patient’s health status.

Document chronic conditions at least annually. Such conditions should involve aspects of MEAT—monitoring, evaluating, assessing, treating. Note the severity or stage of the condition and document any complications or associated conditions.

Carve ‘Forever Codes’ in Stone

  • CMS considers conditions resolved if not evaluated and coded annually
  • Example Conditions – not an exhaustive list
  • Amputations
  • Transplants
  • Compensated Congestive Heart Failure
  • Ostomies
  • Cirrhosis
  • Diabetes
  • Paraplegia/quadriplegia

Some of the condition listed above—cirrhosis and ostomy, for example—may resolve. Specific documentation, however, begets specific documentation. In other words, when a chronic condition is clearly noted in the patient’s file, annual wellness visits lend themselves to follow-up visits. Monitor, evaluate, assess, and, if necessary, treat. The patient, then, is proactively cared for, and you’ve covered yourself should a resolved condition with the potential to reemerge become problematic. In the interim of stability, CMS gets its annual code.

Tip. Go through your encounter records, print them out if you use an EMR, or pull some charts. Peruse your files for areas in need of better documentation. Look for conditions with potential implications to the future health status of your patients—chronic conditions that have fallen through the cracks. And change your system to keep such conditions front and center. They should be the first thing physicians and coders see when they view a patient’s record.

As well, you might ask yourself if you missed opportunities from a coding selection standpoint or a documentation standpoint. Work together to see where you can fix these issues. Clinical documentation improvement means better reimbursement.

To learn more about CDI and HCC code selection, pick up TCI’s end-to-end Risk Adjustment Primer.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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