![]() ![]() ![]() Complications or manifestations of a disease process should be clearly linked.All diagnoses that receive care and management during the encounter should be reported.All cause-and-effect relationships should be documented.Here are some best practices from AHIMA to ensure high-quality documentation to support HCC reporting: Treatment: Document care being provided for the condition, prescribing or continuation of medications, referral to specialist, ordering diagnostic tests, therapeutic services, other modalities, and plan for managing the chronic condition.Assess/Address: Document the discussion of chronic condition, review of records, counseling, acknowledging, documenting status/level of condition, how the chronic condition will be evaluated, and ordering of further tests.Evaluate: Document the present state of the condition, physical exam finding, test results, medication effectiveness and response to treatment (physical exam findings).Monitor: Document all signs, symptoms, disease progression/regression, disease regression, and ongoing monitoring of the chronic condition (ordering of tests and referencing labs/other tests).To comply with MEAT criteria, the provider must document the following aspects: documentation of each diagnosis in the assessment and care planīy properly documenting each diagnosis in the assessment and plan, providers can demonstrate that they are Monitoring, Evaluating, Assessing and Treating the condition.the history of present illness, physical exam.A well-documented progress note would include the following: Meeting MEAT criteria means properly documenting all conditions evaluated and considered during treatment for every face-to-face visit. To support an HCC, documentation must support the presence of the disease/condition, and also include the clinical provider’s assessment and/or plan for management of the disease/condition. Simply listing diagnoses in progress notes is not acceptable or valid per official coding guidelines, and does not meet the requirement of an assessment and plan. MEAT Criteria to Establish Presence of a Diagnosis MEAT helps coding professionals identify reportable conditions. This coding model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and other aspects. Providers must thoroughly document all chronic disease processes and manifestations in the patient’s medical record for proper Risk Adjustment and HCC coding mandated by CMS. Documentation that meets the MEAT criteria helps providers establish the presence of a diagnosis during an encounter and ensure proper documentation for risk adjustment and Hierarchical Condition Category (HCC) processes. expands to: Monitor, Evaluate, Assess/Address, and Treatment. ![]() Importantly, medical transcriptionists provide complete and accurate clinical documentation that shows evaluation and treatment for all conditions assessed at the time of the encounter and supports MEAT.ĭon’t let transcription requirements take up your valuable time.Ĭontact us to outsource your medical transcription needs. Enabling collection of data for research and education.Supporting appropriate utilization review and quality of care evaluations.Facilitating accurate and timely claims review and payment.Promoting communication among providers and supporting continuity of care.Allowing healthcare professionals to evaluate and plan the patient’s treatment and monitor care over time.Medical transcription services ensure appropriately documented medical records, which is an important element to support high quality care by: MEAT represents four aspects and is a reliable way to ensure proper documentation for risk adjustment and coding. Outsourcing medical transcription ensures that physician-dictated progress notes are converted into text format in an accurate and timely manner. Each diagnosis must be documented clearly and precisely by the physician based on the clinical documentation from the face-to-face patient encounter. According to ICD Coding Guidelines, all conditions co-existing at the time of the encounter that require or affect patient care and management must be clearly documented and assigned a diagnosis code. ![]()
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