Pediatric Coding Alert

Protect patients, providers with these 21 elements, 6 core components, and 5 tips.

Getting such a program off the ground, or even maintaining an existing one, can be a daunting prospect. So, here are some suggestions that will help you examine your medical record documentation more closely than ever before.

Tip 1: Know 6 Core Components of NCQA Guidelines

You may be familiar with the National Committee for Quality Assurance (NCQA), the healthcare accreditation and certification organization responsible for the Healthcare Effectiveness Data and Information Set (HEDIS) performance measurement tool used throughout the healthcare industry. But what you may not know is that they have produced a comprehensive set of Guidelines for Medical Records Documentation that “reflect a set of commonly accepted standards for medical record documentation.”

These standards consist of 21 elements, which include the following six best practices, or “core components to medical record documentation”:

• Significant illnesses and medical conditions are indicated on the problem list.
• Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
• Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.
• Working diagnoses are consistent with findings.
• Treatment plans are consistent with diagnoses.
• There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

(You can view the full NCQA guidelines by going to www.ncqa.org/wp-content/uploads/2018/07/20180110_ Guidelines_Medical_Record_Documentation.pdf).

Tip 2: Document Patient’s Allergies

“Often, audit findings show there is no documentation of medication allergies, adverse reactions, or known allergies [NKA] status,” says Laurie Bouzarelos, MHA, CPC-A, contracting and chart auditing specialist at Physician’s Ally Inc. of Littleton, Colorado. This means you should pay special attention to the second of the NCQA core components.

This means documenting pertinent negatives, as they are “just as important as pertinent positives, and silence in the medical record should not necessarily be interpreted to mean negative or not applicable,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

This “is consistent with the documentation guidelines for evaluation and management [E/M] services related to ROS and the exam, which refer to documenting pertinent/relevant negatives as well as positives,” Moore points out.