Meet the MEAT Criteria to Avoid Overpayments

1. Meet the MEAT Criteria to Avoid Overpayments In a recent article in For the Record magazine , we discussed the use of MEAT – Monitoring, Evaluation, Assessment, Treatment – criteria to comply with ICD-10-CM Coding Guidelines requiring all documented conditions coexisting at the time of an encounter that affect patient care treatment or management be coded as a diagnosis. For instance, well-documented progress notes would include the History of Present Illness (HPI), Review of Systems (ROS), and physical exam, and would also show the medical decision-making process. Each diagnosis must be documented in an assessment and care plan. To ensure this is the case, many organizations use the MEAT criteria for their documentation practices along with Hierarchical Condition Category (HCC) assignments and ICD-10-CM diagnosis coding. MEAT stands for the four factors that establish the presence of a diagnosis during a face-to-face patient encounter and ensure proper documentation: •Monitor for signs, symptoms, disease progression, and disease regression

2. •Evaluate via test results, medication effectiveness, response to treatment, and physical exam findings •Assess/Address through discussion, records review, counseling, acknowledging, and/or documenting the status/level of condition •Treat with medications, surgery, or other therapeutic intervention, refer to a specialist and/or plan for ongoing management During Risk Adjustment documentation and coding, coders use the MEAT formula to help them correctly identify and assign HCC chronic condition diagnoses – which payers also use to account for the overall health and medical cost expectations of each patient enrolled in a health plan. This is vital, as value-based payment models such as Medicare Advantage and Accountable Care Organizations that require providers to carry greater financial risk are becoming the norm. Leveraging MEAT Thorough and complete documentation of chronic condition diagnoses is essential to the risk adjustment and HCC process – and is where MEAT comes into play. Coding professionals need to review all documentation to assign appropriate ICD-10-CM diagnosis codes. Most chronic conditions match to an HCC, which must be supported with documentation showing the presence of the disease/condition. It must also include the clinician’s assessment and/or care management plan. This is where things get complicated; just listing every diagnosis in the medical record does not adequately support a reported HCC code. CMS focuses on these diagnoses to demonstrate the need for higher reimbursement rates for patients who have more serious conditions or problems to manage. If the diagnosis on the claim is not accurate or complete, it could result in a lower reimbursement rate. Thus, an acceptable problem list must show evaluation and treatment for each condition that relates to an ICD code. For example: “diabetes (E11.9) remains stable, will continue insulin 10 units daily" or "patient has panic type anxiety (F41.0) and the patient complains that break through panic attacks have

3. increased. Will add Buspirone 15mg tablets once daily to medication regimen." Further, providers should show evaluation and treatment for all conditions assessed during the encounter as well as ensure that the information is thoroughly documented, for example by including “history of” conditions that affect the current treatment plan. For example, if there is a history of colon cancer (Z85.038) and the patient is ordered to have a screening colonoscopy, be sure to include this information under the A/P. Costly Mistakes Failure to comply with audit-specific diagnosis codes carries a high cost. In early 2022 alone, the Office of the Inspector General (OIG) sought to claw back millions in improper Medicare payments from several Medicaid Advantage organizations it found to be non-compliant with risk-adjusted programs. Among these were Healthfirst Health Plan, Inc., which was overpaid by $5.2 million, and Tufts Health Plan Inc., which received at least $3.7 million in net overpayments.

4. MEAT can help organizations avoid these costly overpayment mistakes by ensuring providers are: •Documenting all conditions evaluated during each encounter •Ensuring a proper progress note with the HPI, physical exam, and medical decision-making process •Documenting each diagnosis in an assessment and care plan •Ensuring that each diagnosis provides evidence that the provider is Monitoring, Evaluating, Assessing/addressing and treating the condition. Without MEAT documented to substantiate the diagnosis, CMS will reject the diagnosis due to lack of evidence by the provider. With more risk-adjusted programs in play and millions at risk of potential overpayment, any trick in the book is fair game when it comes to documenting for HCC. Adopting MEAT criteria allow providers and coders alike to ensure that claims issued based on their documentation and coding are comprehensive, compliant, and accurate. MEAT criteria was also the subject of a recent webinar, which can be accessed here (Meet the M.E.A.T Criteria?). Source of content: AGS Health Blog - Meet the MEAT Criteria to Avoid Overpayments