Your coders understand MEAT criteria basics. Monitor, Evaluate, Assess, Treat. They can identify clear examples of adequate MEAT and obvious examples of inadequate MEAT.
But MEAT criteria isn’t always black and white. There are gray areas where experienced coders make conflicting decisions. These ambiguous situations create inconsistency in your coding and audit risk when CMS takes the stricter interpretation.
The Monitoring Gray Area: How Current Is Current Enough?
MEAT criteria requires monitoring of the condition. But how recent does monitoring need to be?
Your coder reviews an annual wellness visit. The note mentions “CKD stage 3” in the assessment. There’s a GFR value in the lab results section showing GFR of 48. Perfect MEAT, right?
Not if that GFR is from 14 months ago. The provider copied forward the CKD diagnosis and referenced old lab data. There’s no current monitoring of kidney function during this encounter.
Different coders draw the line differently. Some say monitoring counts if it’s within the past year. Others say it needs to be within 90 days. Others say it needs to be from the current encounter.
Who’s right? CMS auditors take the strictest interpretation. If the monitoring isn’t from the current encounter or very recent (within 30-60 days), they’ll question it.
The safe rule: monitoring should be from the current encounter or explicitly referenced as recent. “GFR today is 48” or “most recent GFR from last month was 48” passes. “GFR 48” with a 14-month-old lab date fails.
The Evaluation Gray Area: Stable Counts or Doesn’t Count?
The note says “diabetes stable, continue current management.” Is that adequate evaluation?
Some coders say yes. The provider evaluated the diabetes and determined it’s stable. That’s an evaluation.
Some coders say no. “Stable” is too vague. What specific evaluation did the provider perform to determine stability?
CMS auditors lean toward the second interpretation. “Stable” without specifics doesn’t demonstrate evaluation.
What counts as adequate evaluation? Evidence the provider actually assessed the condition during this encounter. “A1C today 7.2, down from 7.8 last quarter, glucose control improving” is clear evaluation. “Patient reports good compliance with medications, no hypoglycemic episodes” is evaluation. Just “stable” isn’t.
The gray area is conditions that truly haven’t changed and don’t need detailed re-evaluation at every visit. A patient with stable hypothyroidism on levothyroxine might get “TSH normal, continue levothyroxine 100mcg daily” at an annual visit. Is that adequate evaluation?
Technically yes, because there’s objective monitoring (TSH) that demonstrates the condition is being evaluated. But “hypothyroidism stable” without the TSH reference is risky.
The Assessment Gray Area: Copying Forward Diagnoses
The provider’s assessment lists 15 diagnoses. Some were addressed in the visit. Some weren’t mentioned anywhere in the note except the assessment list.
Can you code conditions that appear in the assessment but aren’t otherwise addressed in the note?
The conservative answer is no. If a condition appears only in the assessment list with no supporting documentation in the visit note, it’s probably being copied forward from prior visits without actual evaluation.
But what if it’s a chronic condition that the provider is managing through medication continuations? The patient has CHF on the problem list. The provider continues Lasix and metoprolol. The assessment lists CHF even though the note doesn’t explicitly discuss it.
Some coders say the medication continuations demonstrate treatment, which satisfies MEAT. Some say without explicit discussion of CHF status, you can’t code it.
The safest approach: look for evidence the condition influenced clinical decision-making during this encounter. If medications were adjusted, ordered, or explicitly continued for a specific condition, that’s stronger than a condition just appearing in the assessment list.
The Treatment Gray Area: Continue Current Medications
“Continue current medications” appears in almost every note. Does medication continuation count as treatment for MEAT criteria?
The answer is: it depends on specificity.
“Continue all meds” doesn’t demonstrate that the provider actively managed any particular condition. It’s a blanket statement.
“Continue lisinopril 20mg daily for hypertension” does demonstrate active management. The provider specified the medication and the condition it’s treating.
“Continue Lasix 40mg daily, patient reports decreased leg swelling” is even better. There’s evidence the provider evaluated the effectiveness of the CHF treatment.
The gray area is notes that say “continue diabetes medications” without specifying which medications or providing any diabetes-specific information. Technically that’s treatment. In practice, CMS auditors often challenge these as too vague.
The Multiple Conditions Gray Area: How Many Can You Code from One Note?
A comprehensive note documents evaluation and treatment of eight chronic conditions. Can you code all eight?
In theory, yes. If each condition has adequate MEAT criteria, each condition should be coded.
In practice, coders worry about coding “too many” HCCs from a single encounter. They’ve been told to be conservative. So they code the 3-4 conditions that are most thoroughly documented and skip the others.
This is leaving money on the table. If MEAT criteria is adequately documented for a condition, code it. The number of conditions per encounter isn’t limited.
The gray area is conditions that are mentioned but minimally documented. The note lists ten problems. Three are thoroughly documented with clear MEAT. Five are briefly mentioned with minimal detail. Two aren’t discussed at all.
Code the three with clear MEAT. Query the provider about the five with minimal documentation. Don’t code the two that aren’t discussed.
The Specialist Note Gray Area: Shorthand Documentation
Specialists often use shorthand that assumes clinical knowledge. A cardiology note says “EF 35%, uptitrated carvedilol, continue diuretics.” It doesn’t say “CHF” anywhere.
Can you code CHF based on this note?
Coders with clinical knowledge know that EF 35% indicates heart failure and the medication management is appropriate CHF treatment. But the note doesn’t explicitly state CHF.
Conservative coders say you can’t code conditions that aren’t explicitly documented, even when the clinical picture clearly indicates the condition. Aggressive coders say the supporting evidence is adequate even without the explicit diagnosis.
CMS auditors expect explicit documentation. “EF 35%” isn’t the same as “heart failure with reduced ejection fraction.” Query the specialist to clarify.
The Historical Documentation Gray Area: History of Condition
The note says “history of breast cancer, status post mastectomy 2015, no evidence of recurrence.” Can you code cancer?
No. “History of” indicates a resolved condition. HCC coding requires current, active conditions.
But what about “history of MI, continues on aspirin and statin for secondary prevention”? The MI was historical, but the ongoing treatment suggests the cardiovascular condition remains relevant.
Some coders code the sequelae (atherosclerotic heart disease) rather than the historical MI. Some query the provider to clarify current conditions. Some skip it entirely.
The gray area is conditions that were previously acute but have ongoing chronic implications. The provider uses “history of” language but continues treating complications.
Best practice: code current conditions and sequelae, not historical events. If unclear, query.
What Actually Resolves Gray Areas
Gray areas persist because there’s no definitive guidance on edge cases. Different coders, different QA reviewers, and different auditors interpret ambiguous documentation differently.
You can’t eliminate gray areas entirely. But you can reduce inconsistency.
Create clear coding guidelines for your organization’s interpretation of gray areas. “Monitoring must be within 60 days to count.” “Medication continuations count as treatment only if medication and condition are explicitly linked.” “Code all conditions with adequate MEAT regardless of how many appear in one note.”
Train coders on these standards and enforce them through QA. Accept that your standards might be more conservative than necessary, but consistency is more valuable than squeezing every possible HCC from ambiguous documentation.
And when documentation falls in gray areas, query the provider. Don’t code what you hope is adequate. Code what’s clearly documented or get clarification.
