Coding Tip Corner: Where’s the MEAT?

Coding Tip Corner is returning to the Provider newsletter. Hopefully this can become an interactive section that will keep offices up to date on coding changes and bring attention to what is acceptable and unacceptable in the coding arena.  

Most of the examples in Coding Tip Corner will come from records that have been reviewed for various audits. These will be spotlighted anonymously. This is just another means to keep you informed as changes occur. Providers are treating their patients, and it comes back to you as the coder to determine if there is sufficient MEAT* to code the condition or if a query is necessary. 

*MEAT is a common acronym used to identify reportable conditions when documenting a visit, so that all conditions can be captured accurately. Here’s what it stands for: 

M is for Monitoring: The document includes signs, symptoms, disease progression or regression, continued surveillance, or observational findings. 

E is for Evaluation: the provider has documented the current state of the condition (if chronic), for example, stable, exacerbated, worsening, uncontrolled. There are examination findings, test results reviewed, discussion of medication or treatment efficacy, or notations of the patient’s response to treatment(s). The provider has noted assessment of late effects of a condition or illness. 

A is for Assessment: Documentation exists of the discussion of a chronic condition and how it should be monitored or followed up with a specialist. Records and test results are reviewed. Counseling is provided or a discussion noted about additional evaluation or ordering of additional testing to determine the status of the disease, progression, or regression. Patient care or plans discussed with another provider on the patient’s care team, internally and externally. 

T is for Treatment: The current treatment is documented, reaffirmed, or changed. There is an increase or decrease in medication dosing. A referral to a specialist made, or additional testing, imaging, studies, or therapies are ordered. Patient education is provided related to a specific condition and recommended or ongoing treatment. Additional treatment options are recommended, discussed, or summarized. The treatment plan is reviewed and updated. 

Medical records play a crucial role in reimbursement by providing the documentation necessary to support claims and justify the services provided by healthcare providers. These records are reviewed by payers (insurance companies, government programs) such as the Centers for Medicare and Medicaid Services (CMS) as well as the Office of Inspector General (OIG). When errors are found, reimbursement is required.