AI has the potential via natural language processing to autoscribe the elements of a clinic visit and alter the current physician-computer interface. We do acknowledge, however, that this is an important topic to be considered for future research into best practices for genetic counseling clinical documentation. Clinical documentation in the patient-facing specialty of radiation oncology has increased significantly, threatening physician wellness and meaningful interactions with patients. The best thing you can do is arm yourself with as much knowledge as you can from both CMS and AHA Coding Clinic. This clinical documentation practice resource does not include recommendations related to this type of correspondence. Also, any guidelines not published by CMS or Coding Clinic (both official sources) should be taken with a grain of salt (even these posts on this forum). showing only Science & Medicine definitions ( show all 7 definitions) Note: We have 6 other definitions for M.E.A.T. How much Risk your organization is willing to take on each HCC?,- especially when documentation doesn't fit neatly into any published guidelines. I once listened into a great webinar about Risk Adjustment, and the presenter explained about when it comes down to validating each HCC with either MEAT or TAMPER. Perhaps an educational note to the provider to allow additional information (not much) could tip the scales towards better and improved documentation. While they both may be supported by MEAT and TAMPER, I would like to see a little more information. Others use “TAMPER™”:Į11.9 (Diabetes w/o complications) currently on Metformin 500mg.į33.1 (Major depressive disorder, recurrent, moderate) followed by Dr. Why high-level details in your Clinical Documentation are best: Specifically, your Clinical Documentation supports the ICD -10 Codes submitted on your claims to report the patients care receive d and requires pertinent facts, findings and observations about the patients health and history to be documented in your Progress Note. 13 HCC Guiding Principle The Risk Adjustment diagnosis must be based on clinical medical record documentation from a face-to-face encounter The Diagnosis. T – Treating medications, therapies, other modalities"ĭetails about the MEAT approach are provided in Appendix D.A – Assessing/Addressing ordered tests, discussion, review records, counseling.E – Evaluating test results, medication effectiveness, response to treatment.M – Monitoring signs, symptoms, disease progression, disease regression This is an acronym for documentation guidelines used to describe four requirements used by auditors that can also help providers document the presence of a diagnosis during a patient visit.To break it down, documentation must reflect: "One way to help ensure your documentation is up-to-par for HCC coding is to include MEAT (monitored, evaluated, assessed/addressed and treated) in the medical record for the patient encounter. Increasingly, this documentation, as well as the resultant data and information extracted from that documentation, is how providers and organizations are being measured and adjudicated.
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