By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA

As health information professionals, we have an obligation to promote the integrity of our organization’s health information. Health information integrity means our clinical staff creates documentation that accurately and completely reflects the conditions addressed at the time of encounter and coding professionals strictly apply the CMS Guidelines and RADV rules when assigning the codes to conditions reported.

So how does one know if their manner of coding is going to be acceptable? While there are a number of items to keep in mind when assigning codes, the most beneficial, in my opinion, is ensuring coded conditions are supported by documentation that supports clinical specificity and clearly indicates that the conditions have been addressed. This means that the CMS-approved provider’s documentation reflects that the condition was:

Monitored,

Evaluated,

Assessed or Affected, and/or

Treated.

I know that these bullets refer to M.E.A.T. but there are other guides available that encourage clinicians to document clearly and without excessive effort, such as T.A.M.P.E.R. and D.S.P. However, I don’t want us to assume that any of these acronyms are required by CMS; ironically, they are not endorsed by CMS!

Some have asked if coding should be done from the problem list. My guidance is “no.” Often the problem list is a compilation of any condition the patient may have had and not necessarily solely reflective of the conditions attended to during the encounter. Only those conditions that were monitored, evaluated, assessed/affected, or treated should be coded. (For more about the “problems” with problem list and the key role played by HIM and CDI professionals see my Libman Education course HCC Problem Lists.)

What Can You Do To Promote Information Integrity?

As part of our quality promotion activities, we should review cases coded to determine if any recorded conditions meet clinical specificity and demonstrate they were assessed as well as if any were overlooked by the coding professional or by the provider if the provider does the coding. When omissions are found, properly resubmitting the claim is important. However, when we find that a coded condition does not qualify for claim submission or that a condition was incorrectly coded, resubmission of the claim is imperative to correct the data previously submitted.

I’ve mentioned clinical specificity twice already and probably should clarify CMS’s meaning of this term. “Clinical specificity” involves having a diagnosis fully documented in the source medical record instead of routinely defaulting to a general term or an unspecified diagnosis. This means that health information professionals may find themselves assisting clinicians with cleaning up problem lists, guiding clinicians on documentation elements supported by what the clinician did for the patient and other clinical indications, and adjusting the favorites list so clinicians choose the most explicit diagnoses easier.

Additional quality promotion activities include serving in a clinical documentation integrity role and guiding your providers on the documentation integrity requirements and the specificity required to accurately code conditions. Specific conditions are more likely to achieve a payment HCC and that is always an added plus.