07 Oct 5
Put MEAT in Documentation for Healthy Audits
Submitted by: Angie Hlad, CRN-C, Risk Adjustment and Coding Coordinator
Complete and accurate documentation is the key for impacting quality, safety, efficacy, and data integrity. Additionally, complete and accurate documentation helps safeguard against payment recovery from Medicare in an audit situation.
Medicare wants to ensure payments to PACE organizations match the expected costs of care. In order to accomplish this, CMS scrutinizes health plans with both random and targeted audits for validity of diagnoses submitted. To prevent payment recovery to Medicare, there are several elements that must be present in the medical record; one of those elements is documenting a diagnosis. Let’s examine this element.
The Official ICD-9 Coding Guidelines state that a condition must exist at the time of the encounter and affect patient care or management and be documented in order to be coded as a diagnosis. M.E.A.T. is an acronym used to describe four factors that help providers to establish the presence of a diagnosis during an encounter in proper documentation.
M.E.A.T. is an acronym for:
Providers are required to document all conditions evaluated during each face-to-face visit. A proper progress note would include the HPI, physical exam and show medical decision-making process. Each diagnosis must be documented in an assessment and care plan and each diagnosis must show that the provider is Monitoring, Evaluating, Assessing/addressing or Treating the condition. A simple list of diagnoses is not acceptable or valid per official coding guidelines, nor does a simple list meet the definition of ASSESSMENT and PLAN. Here is a breakdown of what M.E.A.T. might look like:
- Monitoring– signs, symptoms, disease progression, disease regression
- Evaluating– test results, medication effectiveness, response to treatment
- Assessing/Addressing– ordering tests, discussion, review records, counseling
- Treating– medications, therapies, other modalities
According to CMS an acceptable problem list must show evaluation and treatment for each condition that relates to an ICD-9 code. Some examples of supported documentation are as follows:
- CHF: 428.0- symptoms well controlled with Lasix and ACE inhibitor. Will continue current medications
- Major Depression: 296.20- Patient continues with feelings of hopelessness and anhedonia despite current regiment of Zoloft 50 mg daily. Will increase dose to 100 mg daily and monitor
- HTN: 401.9- stable on medications
Not only should providers show evaluation and treatment for all conditions assessed at the time of the encounter, they also should not sell themselves short of their hard work. Often, conditions may be addressed and treated, but do not make it to the A/P. Treatment is prima facia evidence of a diagnosis – if you are treating, it therefore exists. It is acceptable to include “history of” conditions if it affects the current treatment plan. For example: if there is a history of breast cancer and the patient is ordered a mammogram. Remember though that stating “history of” means the patient no longer has that condition.
- Any and each condition that is addressed at the time of the encounter should be documented in the A & P.
- Each condition that relates to an ICD-9 code must show evaluation and/or treatment. A list of diagnoses is not acceptable as evidence that the diagnosis affected patient management.
- Using M.E.A.T. ensures that documentation suffices CMS’s requirements for supporting and validating diagnoses.
Following these principles will provide for accurate documentation, quality patient care, and an improvement in data integrity by validating diagnosis codes.
*The information presented here complies with accepted coding practices and guidelines as defined in the ICD-9-CM coding book. It is the responsibility of the healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM code(s) according to the official coding guidelines.
*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.