In an effort to help you and your office staff with the increasing importance and complexity of quality and risk adjustment documentation and coding, HealthCare Partners created some valuable tools.
These tools will assist you and your office staff in reaching your quality and risk adjustment documentation and coding goals while reducing time spent on administrative functions and increasing the time available for patient care.
Annual Wellness Visit Form (AWV) and Coding Guide
Use the form to document your patients’ Annual Wellness Visits (AWVs) and to develop personalized prevention plans to help keep them healthy. Your personal progress notes, electronic medical records (EMR), or continuation sheet(s) can be used to supplement this form as needed.
Note: Appropriate coding for services rendered during the AWV has been included on the form for your reference.
Coding Guides and Tip Sheets
These guides will give you and your office staff additional tools for risk adjustment, coding, and documentation. These guides are intended to be used as a reference for frequently documented risk-adjustable ICD-10-CM diagnoses and ensure diagnoses are substantiated within the clinical documentation guidelines.
- Provider HCC Risk-Adjusted Diagnoses with COVID-19 Updates – Correct Coding Guide 2020
- 2020 HCC Coding and Documentation Tips with COVID-19 Updates
- Telehealth and COVID-19: 2020 Coding and Billing Tips
- Medicare Telehealth Services Guide(Source: Medicare CMS.org)
Note: For Medicare and Medicaid’s full list of Telehealth Services, click here
Improving Telehealth Communications
These guides are intended to be used as reference tools when conducting TELEHEALTH visits with your patients.
- Telehealth Communication Tips for Phone/Video
- COVID-19 Communication: Quick Tips to Connect (ACH)
- COVID-19 Telehealth: Relationship-Centered Communication Skills (ACH)
HEDIS® Coding Guide
This guide will give you and your office staff an additional tool for coding HEDIS® measures. This guide is intended to be used as a reference for the current and most frequently used codes that meet HEDIS® requirements, resulting in minimized chart retrievals due to appropriate claims/encounter data submissions.
These desk references provide guidelines for preventive health services, as well as condition/diagnosis documentation in the medical record.
Medical Record Documentation Best Practices
Medical Record documentation is imperative to providing accurate and timely patient care. Clear and concise documentation ensures seamless continuity of care.
- Medical Record Documentation Best Practices
- Documenting M.E.A.T. (Monitoring, Evaluating, Assessing, Treating)
- SOAP Note
Care of Older Adults
When looking to improve the Care of Older Adults, providers should look at Advanced Care Planning, Medication Review, Functional Status Assessment, and Pain Assessment. For detailed information, use this COA TOOL.
Patient Experience and Satisfaction
- The Key to a Successful Practice – Improving the Patient Experience
- Tips for Improving Patient Satisfaction – These important tips can be posted in your office to serve as helpful reminders
- Quality – Health Outcomes Survey Information and Provider Tips
- Education Series Webinar: Improving Patient Experience and the CAHPS® Survey
Behavioral Health Tools
Recognizing the signs of a behavioral health condition is not always easy. We are providing you with the following behavioral health screening tools to help you diagnose and refer individuals for further care. Utilizing these tools when appropriate and submitting the applicable codes will help you to satisfy HEDIS® behavioral health measures.
- EmblemHealth-HCP Your Behavioral Health Screening Tools Pocket Reference
- EmblemHealth-HCP Behavioral Health Screening Tools Scoring and Action Steps
Patient Health Questionnaire (PHQ)
The purpose of the PHQ-2 is to screen for depression in a “first-step” approach. A PHQ-2 score ranges from 0-6. A score of 3 is the optimal cut-point when using the PHQ-2 to screen for depression. The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past two weeks. The PHQ-2 includes the first two items of the PHQ-9.
Patients who score 3 or greater on the PHQ-2 should be further evaluated with the PHQ-9, other diagnostic instruments, or direct interview to determine whether they meet the criteria for a depressive disorder.
The purpose of the AUDIT is to screen and identify excessive drinking and alcohol use disorders. The AUDIT-C is a modified version of the AUDIT Tool.
HCP is working closely with our health plan partners to increase the quality and efficiency of pediatric screenings for children. This guide covers best practices for child screenings within their first 1,000 days of life. Topics covered include identification, prevention, diagnosis, treatment, and follow-up care for lead screening, newborn hearing loss, and developmental screening. As part of this initiative, we are encouraging the use of CPT Code 96110 with a modifier CG or ICD-10 code Z13.41 for developmental screenings, and CPT Code 83655 for lead screenings. Early screening for these conditions is critical to the growth and healthy development of children.
Find some useful information in these articles to support compliance with HEDIS® and CAHPS® measures. Learn more about specific topics: