Question CRC documentation question

Sarah Ann

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It could be me.

One of the questions I have is regarding conditions that we can always code in the absence of provider documentation-- what?

Here's an example of one of the modules-

HPI Mr. Jones presents today for follow up to his recent visit for anginal episodes. We started him on Ranexa and he reports that it's helped. His latest EKG looks good. Pt. had a prior CABG in 05. He is actively working. His COPD acts up with humid weather.. He's been using his rescue inhaler more frequently in the Summer.

Assessment/Plan angina: stable on Ranexa. encouraged him to continue with healthy lifestyle changes.
CAD s/p CABG. repeat nuc. stress test. cont. with beta blocker and statin.
HTN: controlled with lisinopril.
COPD advised to avoid exercising in humid weather.

The documentation supports- angina, CAD,HTN, COPD I get it MEAT/TAMPER I would have coded it that way in real life.

There are several examples that are just like that they demonstrate MEAT.

NOW I'm reading that this isn't necessary with certain conditions like CAD.

I don't understand why they give examples like the one above, and then a few chapters later according to CMS RAPS you can code those dx's without MEAT? WHAT??

Then I'm reading all dx's must be documented in the face to face encounters. A problem list alone will not support the dx's reported.

So what if I FIND CHF, CAD Etc . on the problem list are they saying in essence they CAN be coded in the absence of supporting documentation? I'm confused because I thought we NEEDED the documentation during the encounter, with MEAT and or TAMPER for the conditions to be coded.
I guess I'm confused.
If anyone can clear up this confusion it would be helpful. I just think I'm seeing conflicting information.


Gulf Coast - GCAPC
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This might help, or confuse you further, I don't know. :)

Lifelong conditions don't need MEAT/TAMPER to support them.

Yes, RA/HCC coding HAS to be captured in a face to face encounter. Office visit, Hospital encounters, Echocardiograms can be used...anything where the qualified, acceptably credentialed provider is interacting with the patient.

Assessments...A/P - Assessment and Plan...I/P - Impression and Plan. Anything here that the doctor assesses should be captured, even in the absence of a long as there is no conflicting documentation in the rest of the encounter note.

Used to, we couldn't capture anything from the Problem List without support...and that is still true in certain instances, but lately, with the advent of MACRA, CMS notes that physicians are to keep an 'Active' Problem List of conditions that are current. Their definition of a problem list: 'A list of current and active diagnoses as well as past diagnoses relevant to the care of the patient". So, if 'there is no conflicting or contradictory documentation in the encounter note, a chronic condition should be captured'. That means you have to use your common coding sense to read those lists with discernment...because there may still be an active cancer diagnosis when the documentation also notes the cancer has been surgically removed. <----that's what is meant by conflicting documentation.

Anyway, sometimes a note will have an active Problem List AND a PMH section. In that case, usually anything in the PL can be captured, especially if it is a lifelong condition. Anything from the PMH could be captured with supporting language or medication in the rest of the note.

If the surgical history section of the note documents a CABG, then we know the patient has CAD. CAD is lifelong. CAD isn't necessarily eradicated by having a CABG. Sometimes the bypass vessels become occluded again. Or other vessels are still occluded. Anyway, straight CAD codes don't risk adjust, (unless it is for RxHCC) but CAD w/ Angina does, (I25.110 - I25.119) so unless you are instructed to capture all diagnosis codes, I wouldn't worry about CAD.

CMS actually has a list of what they consider lifelong conditions, but I don't know where the link is to that.

COPD is a lifelong condition. Once a patient has it, it can always be picked up.

CHF...remember this patient has HTN. Check to see if there are CHF meds, or it was listed as 'Chronic systolic/diastolic'. But when you get ready to capture CHF, since the patient has HTN, under the 'with' guidelines in ICD-10, when you look up HTN, under 'with' you'll see Heart Failure, it instructs you to use I11.0 with the proper code for the type of heart failure, I50 - I50.9. When a physician puts a diagnosis in the Assessment, it is their definitive statement that the patient has a condition. Many Risk Adjustment coders believe we still need support even if a diagnosis is in the Assessment. However, if there is no conflicting documentation, we are to capture those. We aren't doctors. We aren't suppose to second guess the doctors. But, if they still code a cancer as active, when the rest of the documentation says it's been eradicated...(conflicting documentation), then we have the ability to correct it according to RA guidelines.

RADV -(Risk Adjustment Data Validation) auditors, have very specific guidelines to follow, and they are the last line in auditing a note and are used by CMS to make sure the guidelines are met. They can pick up things in a PL or PMH, so it's not out of the question that we, too, may pick up conditions in the Problem List.

If you are working, your company may interpret more liberally or more conservatively...depending on what their legal department is comfortable with.
Here's what my company has determined from the CMS RADV guidelines. If you're not working and just studying for a test...pretend that they want you to use CMS guidelines and I would lean towards using them as being liberally, or literally interpreted. Ha!

Problem List - without a PMH list, any HCC diagnosis can usually be captured from this list in the absence of conflicting documentation. Because of CMS definition of a Problem List, they understand, and take it to mean, that the conditions found there are current and affect management of the patient. But if you see that the doctor or someone uses a problem list as a dumping ground for any old complaint and it never falls off the list even if has resolved or been eradicated...then that would be conflicting documentation and don't use those diagnoses.

PMH list - when there is no Problem List...treat as a Problem List, but look out for conflicting documentation. PMH lists make me nervous because of the word 'Past'. I tend to look more carefully for support with a PMH list vs. a Problem List. If I see a lifelong condition though, I do capture it. Usually anything lifelong will have a med or some sort of history noted regarding that condition. Maybe the patient does not want to follow the usual treatments or take the meds...and that is still support for the condition.

A note that has both a Problem List and a PMH list. Capture chronic conditions from the Problem List (in the absence of conflicting documentation) and only capture chronic conditions from the PMH with support.

A problem list and a PMH list must be part of the encounter note documentation. In some EMR's you'll see a Problem List either before or after the body of the encounter note, which nullifies the lists.

All of this takes RA coders a loooong time to grasp and get comfortable with, so don't get stressed out too much. And, the company you work for might have different ways they want you to handle it. I'm just letting you know how my company interpret CMS guidelines on Problem/PMH lists.

I didn't mean to write a novel, but I'm always frustrated with people who answer a question with too little information. :) Let me know if this is just way too confusing. If you're trying to prepare for a test, it does seem weird that they'd want you to know something that you haven't gone over yet.


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Just see it like that: <<All conditions or diseases need support to be validated. >>

Now the question is: what do you consider as SUPPORT?

A condition (whatever it is in Problem list or PMH list or Assessment) can be supported different ways:

  • Signs or symptoms (If the patient is Symptomatic) as numbness for DM polyneuropathy or weak pedal pulses for Peripheral Vascular Disease.
  • If asymptomatic:
    • Test results (Lab and Imaging ) with the Date it was performed. Like Chest X-ray (12/23/2019) shows Atherosclerosis of Aorta.
    • Treatment drugs ;like patient on Gabapentin for DM polyneuropathy
    • Referral; like patient with COPD is referred to pulmonologist.
    • Status for chronic condition (CHF /COPD /SSS /Cardiomyopathy /RA); like:
      • Stable
      • Improved
      • Controlled in medication
      • Worsening
      • In remission
How the condition will be managed is very important to be documented. Since documentation clarification is a MUST, make sure before submitting claims that the medical record documentation:

  • Is not conflicting/contradictory
  • Is not imprecise/ambiguous/incomplete.

Sarah Ann

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We don't pull anything off the problem list (I code urgent care accounts). They could come in for a finger laceration--but the problem list follows them from their primary care phys. office. I would think it needs to be firstly mentioned by the provider in the note during that(face to face) encounter)🤔 before we look for support to code that correct?