HCC Chronic Conditions and M.E.A.T. Criteria
HCC Chronic Conditions
As a follow-up to our previous articles “The HCC Coding Specialist: Benefiting payers, providers, and patients” and “HCC Medicare Advantage background and overview,” we now review HCC chronic conditions and the M.E.A.T. documentation criteria.
HCC risk adjustment is a fundamental method used in health insurance payer programs to account for the overall health and expected medical costs of each individual enrolled in a healthplan. Currently, as millions of Baby Boomers enter their Medicare years, the focus is now on how to effectively address the high prevalence of chronic conditions among Medicare beneficiaries. For example, from the Centers for Medicare & Medicaid (CMS) 2017 data, 57% of Medicare beneficiaries have been diagnosed with hypertension and 41% with hyperlipidemia (high cholesterol).
Also, according to the most recent CMS 2017 data, over two-thirds of Medicare beneficiaries are living with two or more chronic conditions, which equates to 94% of the overall Medicare spending.
Active, efficient, and effective management of these chronic conditions is critical to ensuring that Medicare beneficiaries receive the best possible care and that the Medicare program is sustainable. Accurate and complete documentation of chronic condition diagnoses by clinicians is an essential component of the risk adjustment and HCC process. Providers are required to document all conditions evaluated during every face‐to‐face visit.
Coding professionals need to review the entire medical record documentation to assign appropriate ICD-10-CM diagnosis codes. Most chronic conditions are assigned to an HCC. 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. Most organizations use the “M.E.A.T.” criteria: Monitoring, Evaluation, Assessment, Treatment for their documentation practices, as well as ICD-10-CM diagnosis coding and HCC assignments.
The CMS conducts risk adjustment data validation (RADV) to ensure the accuracy and integrity of risk adjustment data submitted for Medicare Advantage (MA) risk adjustment payments. RADV is the process of verifying that diagnosis codes submitted for payment by a MA organization are supported by medical record documentation. Simply listing every diagnosis in a problem list does not support a reported HCC code.
Remember, CMS “wipes the slate clean” every January 1, so MA plans must recapture all chronic conditions in order to receive reimbursement. Now is the time to review your providers’ documentation practices and coding guidelines. Utilizing the M.E.A.T. criteria for provider documentation is one of the most effective ways to ensure HCC coding accuracy.