Fall 2022

Documentation Dilemmas: Does Your Documentation Meet the MEAT Criteria?
By Leigh Poland, RHIA, CCS
For The Record
Vol. 34 No. 4 P. 26

ICD-10-CM coding guidelines state that all documented conditions coexisting at the time of an encounter that require or affect patient care treatment or management must be coded as a diagnosis. As such, physicians must clearly and precisely document each diagnosis based on clinical medical record documentation from a face-to-face encounter, which means that diagnoses cannot be completely determined from test results and a patient’s past medical history.

For example, well-documented progress notes include the history of present illness, review of systems, and physical exam. They also detail the medical decision-making process. Each diagnosis must be documented in an assessment and care plan. To ensure this is the case, many organizations use the “MEAT” criteria—monitoring, evaluation, assessment, treatment—for their documentation practices, along with hierarchical condition category (HCC) assignments and ICD-10-CM diagnosis coding.

But what are the MEAT criteria and how should they be applied in code assignments?

A Little History
Simply put, MEAT stands for the four factors that establish the presence of a diagnosis during face-to-face patient encounters and ensure proper documentation:

• Monitor for signs, symptoms, disease progression, and disease regression.

• Evaluate via test results, medication effectiveness, response to treatment, and physical exam findings.

• Assess/address through discussion, records review, counseling, acknowledging, and/or documenting the status/level of condition.

• Treat with medications, surgery, or other therapeutic intervention; refer to a specialist; and/or plan for ongoing management.

During risk adjustment documentation and coding, coders use the MEAT formula to help them correctly identify and assign HCCs, which payers use to account for the overall health and medical cost expectations of each patient enrolled in a health plan. With value-based payment models such as Medicare Advantage and accountable care organizations that require providers to carry greater financial risk becoming the norm, correct assignment of HCCs is vital.

According to CMS, more than two-thirds of Medicare beneficiaries were living with two or more chronic conditions in 2017, accounting for 94% of the overall Medicare spending. Proper management of these conditions is critical to ensuring both quality of care and the financial sustainability of providers and programs.

Leveraging MEAT
Accurate and complete documentation of chronic condition diagnoses is an essential component of the risk adjustment and HCC processes. This is where MEAT comes into play—by ensuring that providers are properly documenting all conditions evaluated during every face-to-face visit.

To assign appropriate ICD-10-CM diagnosis codes, coding professionals must review the entire medical record documentation. Most chronic conditions match an HCC. To support an HCC, documentation must support the presence of the disease/condition. It must also include the clinician’s assessment and/or care management plan.

This is where things get a bit more complicated—just listing every diagnosis in the medical record does not support a reported HCC code. CMS focuses on these diagnoses to demonstrate the need for higher reimbursement rates for patients who have more serious conditions or problems to manage. If the diagnosis on the claim is not accurate or complete, it could result in a lower reimbursement rate.

Therefore, an acceptable problem list must show evaluation and treatment for each condition that relates to an ICD code. This could include documentation such as “diabetes (E11.9) remains stable, will continue insulin 10 units daily” or “patient has panic type anxiety (F41.0) and the patient complains that break through panic attacks have increased. Will add Buspirone 15 mg tablets once daily to medication regimen.”

Furthermore, providers should not only show evaluation and treatment for all conditions assessed during the encounter but also ensure that the information is thoroughly documented. For example, “history of” conditions that affect the current treatment plan must be included. If there is a history of colon cancer (Z85.038) and the patient is ordered to have a screening colonoscopy, be sure to include this information under the assessment and plan.

Accuracy and Compliance Risks
Ample evidence exists as to why compliance with audit-specific diagnosis codes through appropriate application of MEAT criteria depends on documentation. In early 2022, the Office of Inspector General (OIG), on behalf of CMS, sought to claw back millions in improper Medicare payments from the following three organizations it found to be noncompliant with risk-adjusted programs.

Healthfirst Health Plan: The OIG published a review of whether select diagnosis codes that Healthfirst Health Plan, a Medicare Advantage organization, submitted for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by selecting 240 unique enrollee-years with high-risk diagnosis codes for which Healthfirst received higher payments in 2015 and 2016. The OIG found that the diagnosis codes Healthfirst submitted for 155 of the 240 enrollee years were not supported by the medical records. As a result, Healthfirst received an estimated $5.2 million in net overpayments. The OIG recommended repayment and suggested HealthFirst identify and return any similar overpayments.

Tufts Health Plan: This Medicare Advantage organization based in Watertown, Massachusetts, which provides coverage to approximately 107,000 enrollees, was paid approximately $2.3 billion to provide coverage in 2015 through 2016. An OIG audit sampled 212 unique Medicare Advantage enrollee-years with high-risk diagnosis codes for that time and found just 58 of the 212 sampled validated HCCs, while the remaining 154 had diagnosis codes that were unsupported in the medical record.

Based on the sample result, the OIG estimates that Tufts received at least $3.7 million in net overpayments for high-risk diagnosis codes in 2015 and 2016. It recommended repayment as well as identification of similar instances of noncompliance for the high-risk diagnoses included in the audit and repayment in that amount.

SCAN Health Plan: The OIG published a review of whether select diagnosis codes that SCAN Health Plan, a Medicare Advantage organization, submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by selecting 200 enrollees with at least one diagnosis code that mapped to an HCC for 2015. It examined 1,577 HCCs associated with those enrollees to determine whether the medical records supported the use of those diagnosis codes.

The OIG found that 164 of the 1,577 sampled HCCs were not validated by the medical records. Risk scores, therefore, should have been based on a lower number of HCCs. It was estimated that SCAN received at least $54.3 million in net overpayments due to these incorrect HCCs and their effect on risk scores.

The OIG recommended that SCAN refund the federal government the $54.3 million in net overpayments and improve its policies and procedures to prevent, detect, and correct noncompliance with federal requirements for diagnosis codes that are used to calculate risk-adjusted payments. SCAN disagreed and the OIG later revised its determination for the number of nonvalidated HCCs, reduced the estimated overpayments from $66.9 million to $54.3 million, and revised the wording of one of its recommendations.

Ultimately, MEAT is at the crux of risk adjustment. Documentation for a valid diagnosis must provide evidence of how the condition is monitored, evaluated, assessed, or treated for it to be captured for risk adjustment. To adhere to MEAT, providers should do the following:

• document all conditions evaluated during each encounter;

• ensure a proper progress note with the history of present illness, physical exam, and medical decision-making process;

• document each diagnosis in an assessment and care plan; and

• ensure that each diagnosis provides evidence that the provider is monitoring, evaluating, assessing/addressing, and treating the condition.

Without MEAT documented to substantiate the diagnosis, CMS will reject the diagnosis due to lack of evidence.

High Stakes
With more risk-adjusted programs in play and millions of dollars at risk of overpayment, any trick in the book is fair game when it comes to documenting for HCCs. Adopting MEAT criteria allows providers and coders alike to ensure the claims issued based on their documentation and coding are comprehensive, compliant, and accurate.

— Leigh Poland, RHIA, CCS, (leigh.poland@agshealth.com) is vice president of AGS Health’s coding service line.