The Importance Of Assessing All Chronic Conditions During The First Annual Visit​

MRA Corner

Identifying and recording chronic conditions early in the year is a cornerstone of effective patient care and risk adjustment. During this time, we have a unique opportunity to comprehensively evaluate and document all chronic conditions a patient is managing.

Why The First Visit Matters

The first visit of the year sets the tone for the patient’s annual care plan. During this encounter, providers can:

• Review and update the patient’s medical history

• Assess all ongoing chronic conditions

• Document any changes or new developments in the patient’s health status

• Establish a care strategy that includes all relevant diagnoses

Accurately coding chronic conditions during this visit is critical for creating a comprehensive clinical picture. This ensures that payers and other healthcare providers have the necessary information to support the patient’s treatment and care.

Coding Chronic Conditions: Key Guidelines

When documenting and coding chronic conditions, medical coders should follow the official ICD-10-CM guidelines:

1. Guideline IV.I: Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

2. Guideline IV.J: Code all documented conditions that coexist at the time of the encounter and that require or affect patient care, treatment, or management. Avoid coding conditions that were previously treated and no longer exist, unless history codes (categories Z80-Z87) are relevant.

These guidelines emphasize the importance of coding chronic conditions impacting the patient’s care or management, ensuring every aspect of their health is accounted for.

Applying The MEAT Criteria

To determine which chronic conditions to code, providers and coders can use the MEAT framework:

• Monitoring: Signs and symptoms, disease progression, or regression

• Evaluating: Test results or the patient’s response to treatment

• Assessing: The patient’s condition, including reviewing records and providing counseling

• Treating: Interventions, such as medication or other modalities

Even if only one component of MEAT applies, demonstrating the medical necessity for coding the condition is sufficient.

Personal History And Its Impact On Care

Conditions that have been treated and resolved should not be coded as current conditions. However, history codes may be used as secondary codes if they influence current care or treatment decisions. For example, a history of cancer may inform the provider’s approach to monitoring and preventive care.

Common Pitfalls In Chronic Condition Coding

A common mistake is assigning codes for conditions listed only in the patient’s history, problem list, or medication list without evidence that the condition affected the encounter. Providers must document how a chronic condition impacted the patient’s care or management during that specific visit.

For instance, a patient with hypertension noted in their history should only have the condition coded if the provider monitored, evaluated, assessed, or treated the hypertension during the encounter. Clear and thorough documentation is key to ensuring compliance with coding guidelines.

Benefits Of Early Documentation

Assessing and documenting all chronic conditions during the first visit of the year offers several benefits:

• Continuity of Care: Provides a comprehensive health summary for other providers and settings

• Risk Adjustment: Supports accurate risk scores for value-based care programs

• Enhanced Patient Outcomes: Helps providers tailor treatment plans based on the patient’s complete health profile

Code With Confidence

By adhering to ICD-10-CM guidelines and applying the MEAT criteria, providers and coders can confidently identify chronic conditions in the outpatient setting. This process ensures that all relevant conditions are documented, coded, and addressed, setting the foundation for a successful care plan throughout the year.

At Genuine Health Group, we emphasize the importance of comprehensive chronic condition assessment and documentation. Let’s work together to ensure every patient receives the care they need and deserve, starting with the very first visit of the year.

For more information about documentation and coding, please email mra@genuinehealthgroup.com.