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Medicare Advantage

Risk Adjustment and Coding Academy


Coding | Risk Adjustment | Documentation | Training

Top Ten Medical Record Documentation


and Coding Tips
The following documentation tips can help ensure accurate medical coding and
billing compliance for Medicare risk adjustment. These tips are based on the Centers
for Medicare & Medicaid Services (CMS) requirements for Medicare Advantage
plans, Official ICD-9-CM Guidelines for Coding and Reporting, and American
Hospital Association (AHA) Coding ClinicTM guidelines.

Additional Resources:

Centers for Medicare


and Medicaid Services
(CMS) requirements
for Medicare
Advantage Plans
Official ICD-9-CM
Guidelines for Coding
and Reporting

1. State the diagnosis to the highest level of specificity


Document all conditions treated at least annually and more frequently
as required by treatment guidelines.
Expressly state conditions. Probable, suspected, questionable, rule out
or working diagnoses cannot be reported to CMS as valid diagnoses in
an outpatient record.
Clearly document how the reported condition was monitored, evaluated,
assessed/addressed or treated (MEAT).
Use appropriate descriptors to increase the specificity in documentation
2. Create a clear relationship to the diagnosis (Causality)
Show a clear, causal relationship between any condition and its
respective manifestation(s).
Use linking verbiage such as due to, because of or related to to
establish this relationship.
o The word with does not establish a cause-and-effect
relationship except in the case of diabetes with neuropathy
Coding guidelines prohibit coders from making assumptions.
o If there is no clear causal link from one condition to the other, it
cannot be coded as a manifestation of another disease.
3. Include all conditions related to health status
Document chronic and permanent diagnoses as often as they are

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assessed or treated
Document chronic and permanent diagnoses when they are a
consideration in the patients care
Frequently overlooked, but significant conditions include: transplant
status, quadriplegia, dialysis status, current ostomies, amputations, and
asymptomatic HIV infection.

4. Use history of only when appropriate


Per ICD-9-CM guidelines, the term history of means the patient no
longer has the condition
Avoid using the words history of to document a current condition
Frequently used examples include:
o history of congestive heart failure to indicate compensated
congestive heart failure
o history of atrial fibrillation to indicate atrial fibrillation
controlled by medication
5. Standard abbreviations
Use only standard abbreviations.
Avoid the use of abbreviations in medical record documentation
Do not create your own abbreviations

Additional Resources:

Centers for Medicare


and Medicaid
Services (CMS)
requirements for
Medicare Advantage
Plans

Official ICD-9-CM
Guidelines for Coding
and Reporting

6. Complete and legible documentation


Documentation should be clear, concise, consistent, complete and
legible.
The patients name and date of service should be documented on each
page of the record.
Records should be legible to someone other than the provider and
immediate office staff.
Coders and chart auditors (including Medicare) will not guess at what
you are stating.
7. Signature Requirements
Documentation must contain an acceptable provider signature and
credentials.
Acceptable signatures and credentials include:
o Legible handwritten signature, credentials, and date; and
o Electronic signature, credentials, and date. This requires
authentication by the provider (e.g. approved by, signed by,
or electronically signed by).
Unacceptable signatures include signature stamps, typed signatures, and
illegible signatures.
8. The chart problem list should be up to date and include:
Each condition and the start date.
The end date if the condition no longer exists.
The reason why the patient is disabled (Medicare beneficiary and under
65 years).
*A current problem list is important so other providers can know the
medical condition of your patient. Also serves as a reminder to address
each condition at least once a year.

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9. Know the Rules of the Road


Become familiar with the coding conventions and follow all
instructions related to specific codes.
Be aware of includes and excludes instructions and inclusion terms,
as well as use additional code and other code-related instruction in
the Official ICD-9-CM Guidelines for Coding and Reporting.
Locate the code first in the alphabetic index, then verify the code in the
tabular index. Reliance on only the alphabetic index or tabular index
can lead to coding errors.
The American Hospital Association (AHA) Coding ClinicTM is the CMS
approved resource for clarification of ICD-9-CM. Volumes are
published quarterly and contain new or updated information on the use
of ICD-9-CM as well as clarification of previously published coding
advice.
10. Research the ICD-9 book to find the correct code. The book will:
Provide coding guidelines and inform you of any additional code(s)
needed.
Supply you with the correct number of digits.
Inform whether a code is valid (ICD-9 codes change annually on
October 1st).

Additional Resources:

Centers for Medicare


and Medicaid
Services (CMS)
requirements for
Medicare Advantage
Plans

Official ICD-9-CM
Guidelines for Coding
and Reporting

Y0071_11_12559_I_07/01/2011