FLASH: Documentation and Coding Guidance Update

For compliance with coding regulations, ideal and best practice documentation should occur in the History of Present Illness, Assessment and Plan, Review of Systems, Physical Examination, or other similar documentation section. Persisting chronic conditions should be documented throughout the visit note and not only in an active problem or past medical history lists.

Document and report conditions affecting the care and management of the patient at each visit. All reported conditions require M.E.A.T. (monitor, evaluate, assess, or treat) such as linking treatment and/or medications to each condition. It is important to clearly indicate “active” versus “history of” conditions as coders are unable to make assumptions regarding treatment documented in the chart note.

We thank you for your close attention to detail and continued efforts in best practice documentation.  For questions, please contact codingcounts@healthalliance.org.

Reference: AHA Coding Clinic. ICD-10-CM Official Guidelines for Coding and Reporting, effective October 1, 2022. Centers for Medicare and Medicaid Services.