tci General Surgery Coding Alert - 2022 Issue Q2

Implement NCQA Documentation Guidelines for Optimum Medical Record

“Get Your Medical Records in Top Shape With These 3 Tips” on page 5 exhorted you to keep your medical records consistent, current, and complete. To do that, you need to know the core elements that should be in your documentation. The National Committee for Quality Assurance (NCQA) is the organization responsible for the Healthcare Effectiveness Data and Information Set (HEDIS) performance improvement tool, and they emphasize the following six core elements of 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...

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