Compliant Provider Query

[LargoFLSunshine]

We are struggling with provider documentation and MEAT. Would this query be considered leading?

Documentation Deficiency/ Specificity: During the recent encounter, a diagnosis of CKD3 was documented, but the record lacks the current clinical indicators required to validate the status of the disease for risk-adjustment coding. Clinical Indicators: Mandatory documentation per MA plan: Last GFR XX on x/xx/xx on medication names (if applicable). Best practice includes staging CKD3 such as CKD3a or CKD3b.

 

[sls314]

We are struggling with provider documentation and MEAT. Would this query be considered leading?

Documentation Deficiency/ Specificity: During the recent encounter, a diagnosis of CKD3 was documented, but the record lacks the current clinical indicators required to validate the status of the disease for risk-adjustment coding. Clinical Indicators: Mandatory documentation per MA plan: Last GFR XX on x/xx/xx on medication names (if applicable). Best practice includes staging CKD3 such as CKD3a or CKD3b.

What question is the provider being asked? To me, that reads more like an audit result than a query.

 

[LargoFLSunshine]

It is a prospective audit. This is expanding on a query template directly from ACIDS. We are telling the provider we need more MEAT in his future note.