Both Risk Adjustment (HCC documentation and coding) and Quality are two critical aspects of succeeding in value-based care. Documentation of a patient’s medical conditions in the History of Present Illness, Physical Exam, Assessment, and Plan for a given encounter are important not only for HCC coding purposes but also for appropriately determining Quality measure outcomes. The documentation in the note, or that which the provider states about the patient’s medical conditions, must be consistent with that which is coded. Contradictory information within an encounter note is problematic for several reasons; not to mention it is a compliance concern.
In both Quality and HCC coding, the narrative portion of the documentation and coding must match exactly. The word “exact” is one that providers may push back against; however, it is the word that adequately describes that which is necessary to succeed in these two areas.
For example, if a patient’s medical record states that the patient is suffering from clinical Depression, but there is no corresponding ICD-10 code indicating Depression in the Assessment or on the insurance claim; this may result in failing to capture a risk-adjusted diagnosis. Additionally, it negatively impacts the Quality measure of Screening for Depression. If the patient does not have a coded diagnosis of Depression, then the patient would fall into the PREV-12 denominator, meaning that the patient should have a documented screening test (PHQ-9) for Depression. If no such screening is documented, then that medical record does not meet the quality measure.
Mental Health conditions, such as Bipolar Disorder or Schizophrenia, would exclude a patient record from the Depression Screening Quality measure denominator, making it irrelevant to screen for depression.
Providers are under a great deal of stress and the pressures of documenting in the electronic health record are real. Nevertheless, the accuracy and specificity of documenting one’s medical conditions, as well as the internal consistency within a note, are of paramount importance.
Depression screening and diagnosis specificity are not the only examples of where this is important. Another example is when patients have conditions that exclude them from the PREV-13 Statin Therapy Quality Measure, but these are not well-documented. These include situations where a patient may be receiving palliative care, hospice services, or comfort care. Additionally, patients with certain documented myopathies may be excluded from this measure.
Medical record auditors often say, “that which is documented must match that which is coded on the claim.” This can be challenging. But when all providers, scribes, and others involved in documentation understand the significance, there can be equally significant improvements in this area. CHESS is eager to assist in furthering the understanding of the documentation of all medical conditions. Supporting documentation is the foundation and proof of excellent health care.