Mejoras en la documentación de expedientes médicos y la codificación ICD-9-CM
 Humana’s
Medicare Risk Adjustment department continually conducts medical
record reviews in selected physician offices to monitor and improve
medical record documentation practices. The medical record review
process is an opportunity for Humana to work collaboratively with
physician offices and support their efforts. Humana’s staff
can serve as consultants in providing education and resources to
help improve medical record documentation and coding practices.
Good medical record documentation and coding are especially
important in the Centers for Medicaid & Medicare Services (CMS)
Hierarchical Condition Codes (HCC) model of payment to Medicare
Advantage plans. To ensure proper payment, a member’s health
status must be accurately reflected in the medical record documentation
and accurately reflected on the encounter form. According to CMS,
“The CMS-HCC model depends upon accurate diagnosis coding,
which means that the physicians must fully understand and comply
with documentation and coding guidelines for reporting diagnoses.”
Documentation and coding errors may result in improper
condition reporting within the HCC model. Identifying and correcting
these errors can help ensure appropriate reimbursement. Here are
some tips for physicians to help improve documentation and coding
practices for their Medicare patients.
Four key elements to documentation and coding
success:
To ensure prompt and appropriate reimbursement, management
of all Medicare patients should encompass all four of the following.
- Regular patient appointments: While reporting a patient’s
conditions once a year is sufficient, reporting twice a year (once
in the first six months of the year and again in the last six
months) is preferable. Physicians with risk contracts should always
strive to report twice a year to ensure a consistent premium.
- Medical record documentation should be accurate, legible and
complete. Documentation should include the assessment of all conditions
treated or monitored at the time of the visit in support of the
reported diagnoses codes.
- Coding should be accurate, timely, complete and always be to
the highest level of specificity according to CMS and ICD-9-CM
guidelines.
- Data submission should be accurate, timely and complete. The
capabilities of various practice management systems can vary;
physician offices should be familiar with the functionality of
their systems and identify ways to provide all necessary information
to Humana.
Physicians should ask themselves the following
questions about documentation and coding:
- Do we use a superbill that is outdated?
- Do we use software or ICD-9-CM books that are outdated?
- Can we submit more than four codes on one encounter?
- Does our clearinghouse pass more than four codes on?
Using up-to-date superbills, coding tools and clearinghouse
functionality will minimize errors and facilitate coding to the
highest level of specificity. For resources, visit the Web sites
listed below, or call Humana’s local provider connectivity
consultant.
Other potential coding problems include:
- Remembering to include a date with each entry, particularly
on problem lists.
- Ensuring that all entries are legible.
- When using electronic medical records (EMR), remembering that
CMS guidelines require all EMR entries to be reviewed by a physician
and be “electronically signed” or initialed.
For more information about ICD-9-CM documentation
and coding, visit the following Web sites:
www.cdc.gov/nchs/icd9.htm
Official coding guidelines from the Centers for Disease Control
and Prevention
www.aapc.com
Academy of Professional Coders
www.ahima.org
American Health Information
Management Associations
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