According to ICD Coding Guidelines, all conditions co-existing at the time of the encounter that require or affect patient care and management must be clearly documented and assigned a diagnosis code. Each diagnosis must be documented clearly and precisely by the physician based on the clinical documentation from the face-to-face patient encounter. Outsourcing medical transcription ensures that physician-dictated progress notes are converted into text format in an accurate and timely manner. MEAT represents four aspects and is a reliable way to ensure proper documentation for risk adjustment and coding.
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Medical transcription services ensure appropriately documented medical records, which is an important element to support high quality care by:
- Allowing healthcare professionals to evaluate and plan the patient’s treatment and monitor care over time
- Promoting communication among providers and supporting continuity of care
- Facilitating accurate and timely claims review and payment
- Supporting appropriate utilization review and quality of care evaluations
- Enabling collection of data for research and education
Importantly, medical transcriptionists provide complete and accurate clinical documentation that shows evaluation and treatment for all conditions assessed at the time of the encounter and supports MEAT.
What is MEAT?
M.E.A.T. expands to: Monitor, Evaluate, Assess/Address, and Treatment. Documentation that meets the MEAT criteria helps providers establish the presence of a diagnosis during an encounter and ensure proper documentation for risk adjustment and Hierarchical Condition Category (HCC) processes.
Providers must thoroughly document all chronic disease processes and manifestations in the patient’s medical record for proper Risk Adjustment and HCC coding mandated by CMS. Many chronic conditions are HCCs. This coding model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and other aspects. MEAT helps coding professionals identify reportable conditions.
MEAT Criteria to Establish Presence of a Diagnosis
Simply listing diagnoses in progress notes is not acceptable or valid per official coding guidelines, and does not meet the requirement of an assessment and plan. To support an HCC, documentation must support the presence of the disease/condition, and also include the clinical provider’s assessment and/or plan for management of the disease/condition. That’s what makes MEAT relevant.
Meeting MEAT criteria means properly documenting all conditions evaluated and considered during treatment for every face-to-face visit. A well-documented progress note would include the following:
- the history of present illness, physical exam
- the medical decision-making process
- documentation of each diagnosis in the assessment and care plan
By properly documenting each diagnosis in the assessment and plan, providers can demonstrate that they are Monitoring, Evaluating, Assessing and Treating the condition. To comply with MEAT criteria, the provider must document the following aspects:
- Monitor: Document all signs, symptoms, disease progression/regression, disease regression, and ongoing monitoring of the chronic condition (ordering of tests and referencing labs/other tests)
- Evaluate: Document the present state of the condition, physical exam finding, test results, medication effectiveness and response to treatment (physical exam findings).
- Assess/Address: Document the discussion of chronic condition, review of records, counseling, acknowledging, documenting status/level of condition, how the chronic condition will be evaluated, and ordering of further tests.
- Treatment: Document care being provided for the condition, prescribing or continuation of medications, referral to specialist, ordering diagnostic tests, therapeutic services, other modalities, and plan for managing the chronic condition.
Here are some best practices from AHIMA to ensure high-quality documentation to support HCC reporting:
- All cause-and-effect relationships should be documented.
- All diagnoses that receive care and management during the encounter should be reported.
- Complications or manifestations of a disease process should be clearly linked.
- All current diagnoses should be documented as part of the current medical decision-making process and included in the note for every visit.
- Conditions that are no longer active and/or not being treated must not be reported. This includes problem list diagnoses that have been resolved.
- Providers should ensure that all diagnostic codes for the encounter are captured in the electronic health record (EHR) and submitted in the claim.
Medical Transcription Outsourcing supports Accurate and Comprehensive Documentation
Outsourcing medical transcription is an ideal way to ensure EHR-integrated progress notes that are concise, legible, organized, and useful. Good progress notes or SOAP (Subjective, Objective, Assessment, Plan) notes tell the patient’s story. Progress notes integrate various aspects of the patient’s treatment and call attention to important issues relating to care and emphasize patient care and safety. These notes provide information related to medical decision-making, patient-provider communication, critical thinking, billing and coding and medico-legal requirements for documentation. Medical transcription services can go a long way in helping providers in their efforts to thoroughly document evaluation and treatment for all valid diagnosis to meet the MEAT criteria.
Including one or more of the M-E-A-T details at a face-to-face visit for each condition that requires or affects patient care treatment or management will put you on the path to success in capturing risk
Most chronic conditions are assigned to an HCC.
To support an HCC, documentation must support the presence of the disease/condition, and also include the clinical provider’s assessment and/or plan for management of the disease/condition.