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If you have any questions regarding the information in CCA’s provider manual, please email Provider Relations at [email protected].

Section 7: Clinical Documentation And Medicare Risk Adjustment

Clinical Documentation Processes

The Centers for Medicare & Medicaid Services (CMS) use a risk adjustment system to account for medical expenses and care coordination costs for beneficiaries with special needs. As part of that system, CMS requires providers to support all diagnoses billed with “substantive documentation” in the provider’s medical record. Commonwealth Care Alliance and CMS may audit providers at any point for compliance with documentation standards.

The definition of “substantive documentation” is that each diagnosis billed must be supported by three items in the medical record:

1. An evaluation for each diagnosis

  • Assessment of relevant symptoms and physical examination findings at time of visit
  • Only contain diagnoses that are active or chronic and must be identified as such
  • List and address all past and recent diagnosis if they are active and of medical significance

2. A status for each diagnosis to indicate progress or lack thereof: For example:

  • Stable, progressing or worsening, improving
  • Not responding to treatment or intervention

3. A treatment plan for each diagnosis:  For example:

  • Observation or monitoring for exacerbation, responses to treatment, etc.
  • Referrals to specialists or services (e.g. cardiologist or PT)
  • Continuations or changes to any related medications

Coding Compliance

Commonwealth Care Alliance encourages providers to code to the most appropriate level of specificity as a general standard of practice (CPT, ICD10). Commonwealth Care Alliance and/or CMS may audit the provider at any point for over-coding and/or similar billing practices related to Fraud, Waste, and Abuse.

Educational Resources

Providers are encouraged to contact Commonwealth Care Alliance Provider Relations at (800) 341-8478 to request education about coding and documentation compliance.

Behavioral Health Screening Compliance

In collaboration with EOHHS, Commonwealth Care Alliance requires all of it contracted primary care providers (PCPs) to screen and assess each member for behavioral health needs.  The early identification of behavioral health needs can lead to successful referrals, intervention and integrated treatment in a timely manner.

The EOHHS-approved behavioral health screening tool and how to evaluate results can be found in Section 18 Forms in this Provider Manual; how to make a behavioral health specialty care referral can be found in Section14, Provider Credentialing, subsection Role of the Credentialed Primary Care Provider, in this Provider Manual.

CCA recommends the use of the PHQ-9 Depression Assessment Tool, to assess patients for depression.  The tool is a diagnostic measure to assess for Major Depression s well as other depressive disorders. The PHQ-9 can be administered repeatedly to reflect improvement or worsening of symptoms.  

CCA recommends the use of the CAGE-AID Screening Tool to assess the use of alcohol and other drug abuse and dependence.  The tool is not diagnostic but can identify the existence of alcohol or other drug problems.

In addition, CCA recommends that providers conduct a Mental Status exam to further evaluate for other behavioral health symptoms.