Medical Coding and Documentation Tips that Help to Comply with MACRA

Medicare Access and CHIP Reauthorization Act (MACRA) from the time of becoming a law has required the entire physician practices to comply with it due to which they face a lot of challenges in complying with the Quality Payment Program and Merit-Based Incentive Payment System. For the physician practices to comply with MACRA, it is essential that they eliminate any kind of ambiguity in healthcare documentation and maintain the highest levels of medical coding accuracy. Here are some tips that are useful for the professionals in medical coding jobs and help in complying with MACRA.

It is essential for all the practices to consistently and thoroughly document all the medical conditions that are treated and have an impact on the care provided. It is the responsibility of the people in the medical coding jobs to document all the co-existing conditions along with the acute medical conditions that were attended to. Additionally, all those preventive and screening services also have to be documented that have been addressed at the time of patient visit.

Coding should be perfect regarding the present state of medical condition as to if it is acute, chronic, compensated etc.

While documenting it is also necessary to link the medical conditions to other disease processes if there are any. This can be done by using words such as “with”, “due to” or “caused by”. Also, codes reflecting these should be used in the coding process.

All the medical conditions should be documented to the highest levels of specification. In cases where the accurate diagnosis for outpatient services is not available signs and symptom can be used for healthcare documentation.

The healthcare documentation specialists should take every possible caution to document even the history of medical conditions that have been treated and resolved. It should also be taken care that the details of the patient’s non-compliance for treatment, if any, has to be documented appropriately so that all these details give an accurate description of the patient.

The various diagnoses that are part of the services should be sequenced properly to ensure that all the important diagnoses are taken into account for data reporting.

To make the healthcare practices run profitably while complying with the MACRA, it is necessary that the practices outsource their documentation and coding work to the competent medical coding companies.