Population Health

Acuity Documentation and Coding

  • The process of accurately documenting and coding medical conditions that affect evaluation and treatment of patients
  • Patient acuity can only be determined by ICD-10 diagnosis codes on medical claims for patient encounters
  • Supporting clinical information must be clearly documented in associated visit note
  • Chronic diagnoses must be captured at least once every 12 months as patient health status and acuity is re-determined yearly

Goals

  • Improved clinical documentation promotes better patient care and more accurate capture of acuity and severity critical to success in risk contracts
    • Appropriate reimbursement
    • Accurate budget calculation for patient/provider
    • Patient identification
        • Quality metric inclusion or exclusion
        • High-risk care management programs
        • Disease management programs

Documentation and Coding Guidelines

  • The M-E-A-T (Monitored, Evaluated, Assessed or Treated) of the note is generally in the “Assessment and Plan” section but supporting evidence for conditions can be found throughout the note
  • Each diagnosis/condition that is monitored, evaluated, assessed, or treated at the time of the face-to-face visit should be documented
  • Avoid blanket statements such as “all conditions stable, continue meds”
  • Conditions found in the problem list must be documented within your evaluation and assessment in order to be coded

For questions related to acuity documentation or coding initiatives, please contact one of the staff members below:

Kim Ariyabuddhiphongs, MD, Medical Director
Phone: 617-754-1113; Email: kariyabu@bidmc.harvard.edu