Remember to correctly report diagnosis codes

Appropriate diagnosis coding plays a critical role in accurately describing a patient’s condition, underlying conditions and any complicating factors. Here are some key points to keep in mind.

Why is appropriate coding important?
Appropriate coding helps to:

• Ensure appropriate benefit application and payment
• Provide patients with the best care management
• Give an accurate picture of a patient’s overall health
• Reduce on-site reviews

In addition, it will help you as we move into the future. As you may already know, there is a call for increased detail in medical records and appropriate diagnostic coding for things like:

• Quality measures
• Government programs
• Incentive programs (from the Centers for Medicare & Medicaid and from other payers)

Medical records: An essential part of the process
Appropriate coding depends in large part on the information and details included in a patient’s medical record. Here are some important things to keep in mind about medical records:

• Document all of a patient’s existing health conditions. (All chronic conditions must be documented and reported at least once a year.)
• Medical records must support a treated or addressed condition and be signed, credentialed and dated by the physician.
• Documentation in the medical record must provide specific information about the diagnoses.
• Include supporting documentation about all chronic conditions.
• Conditions must follow the M.E.A.T. documentation guidelines in the medical record, indicating that the condition was:
  • Managed
  • Evaluated
  • Assessed
  • Treated
• The medical record is the only source of truth.

Stay tuned: Training classes, articles in The Record
Over the next few months, you’ll have the chance to learn more about appropriate coding through training classes and Record articles. We’ve set up several coding-focused webinars and training sessions. See “Updated training schedule for 2013” and “Blues offer webinars for professional coding services,” both in this issue, for more information.

You’ll also want to check out the article on coding tips in this issue.