Documentation and Coding Tips for MACRA Success

documentation and coding tips MACRA

Posted by Dana Fuhrman on June 22, 2018

The landscape in physician practices is transforming quickly as healthcare moves towards value-based care and quality payment models. Since the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law in 2015, healthcare providers have been struggling to understand and comply with the Quality Payment Program (QPP) and its Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM).  Eliminating ambiguity in physician documentation and achieving consistent coding accuracy are all now even more essential for compliance with these evolving quality based programs. By prioritizing clinical documentation improvement (CDI) and coding quality via the suggestions that follow, your physician practice can be successful under MACRA and maximize reimbursements.

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MACRA has revolutionized physician compensation. To control the rising cost of healthcare while concurrently improving the quality of care, the Centers for Medicare & Medicaid Services (CMS) replaced the traditional fee-for-service payment model with the QPP which rewards value and outcomes by reimbursing physicians using either MIPS or APM. While trying to comply with the complex requirements of MACRA can be challenging, the incentive for physicians is substantial. Starting in 2019, up to 4% of your Medicare Part B payments will be based on your 2017 value-based performance, increasing each year up to the potential maximum adjustment of 9% by 2022 (The Centers for Medicare & Medicaid Services, 2018).

Despite the incentives, a survey from September 2017 revealed that 53% of physician practices are still not participating in value-based care models. The study also concluded that 40% of family physicians do not have a deep understanding of value-based care models and 92% believe the quality expectations are difficult to achieve (American Academy of Family Physicians , 2017).

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If your practice aims for success under MACRA, a good first area of focus is clinical documentation and coding as these elements impact nearly all aspects of value-based care reporting and can greatly impact your bottom line when optimized. Following are some specific documentation and coding tips to help you succeed under MACRA.

Document All Medical Conditions That Are Treated, Managed or Impact Care

It is fundamental to thoroughly, consistently document and code all medical conditions that were treated, managed or impacted care during each patient visit. In addition to acute medical conditions, any coexisting conditions that were managed during the visit or had an impact on any other medical condition that was treated need to be documented and coded. Also include any preventative or screening services that you addressed. Proper documentation and coding will show the patient’s severity of illness and offer a complete depiction of the treatment that you provided during this patient visit (Dunn, 2017).

Document Present State of Medical Conditions

The present state of all medical conditions should be documented and coded for accurate reporting. Be sure to document and code if the condition is acute, chronic, exacerbated, compensated or decompensated. All active chronic conditions must be addressed during a patient visit and documented at least annually (DeVault, Easterling, & Huey, 2017).

Link Medical Conditions to Other Disease Processes

The cause of a medical condition should be documented if it is known. Show relationships between medical conditions and other disease processes by using linking terms such as “with”, “due to”, “caused by” or “secondary to.” Use codes to reflect such relationships. (DeVault, Easterling, & Huey, 2017).

Document to the Highest Level of Specificity

Be as specific as possible when describing medical conditions. If there is not a definitive diagnosis for outpatient services, use signs and symptoms rather than “rule out” or “possible”. Always code to the highest level of specificity. Unspecified codes should be avoided especially when a more specific code could be used to better describe the acuity of the patient (Dunn, 2017).

Document History of Medical Conditions and Noncompliance

When medical conditions are removed or resolved and are no longer under active treatment, document that the patient had a history of that medical condition. Also, document if the patient is noncompliant with treatment. This documentation provides a more accurate description of the patient. History codes should be used in these instances.  (DeVault, Easterling, & Huey, 2017).

Ensure Proper Sequencing of Diagnoses

Sequencing of diagnoses is important to ensure that all significant diagnoses are captured for data reporting. CMS-1500 captures twelve diagnoses per claim. Therefore, sequence your more significant diagnoses within the first twelve diagnoses to ensure they make it to the claim (Dunn, 2017).

Navigating the complexity of MACRA while remaining profitable can be a very complicated process for your practice that strains internal resources. Consider working with a professional medical billing and coding company that understands how to put your data into action for optimized QPP results and reimbursements. HAP provides expert, certified medical coding services that are compliant with MACRA and other legislative mandates.  Ongoing physician education is a core component of these services.   In addition, HAP offers comprehensive revenue cycle management services to support claims submission, payment processes, and practice revenue maximization. Our MIPS Measure Assurance Services can help you understand the program and meet the requirements to maximize your performance. Contact us to learn how we can help your practice succeed under MACRA.

Dana Fuhrman MSN, RN, RHIA, CCS is the Director, HIS Infrastructure Solutions Sales Management at Healthcare Administrative Partners. 

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American Academy of Family Physicians . (2017, September). 2017 Value-Based Payment Study. Retrieved from

DeVault, K., Easterling, S., & Huey, K. (2017, January). Role of Coding and Documentation in the Quality Payment Program. Journal of AHIMA , 88(1), 52-55. Retrieved from

Dunn, R. (2017, June 26). Clobbering MACRA with CDI and Coding . Retrieved from

The Centers for Medicare & Medicaid Services. (2018). The Medicare Access & Chip Reauthorization Act of 2015: Quality Payment Program. Retrieved from