Medicare adjusts payments to Medicare Advantage (MA) organizations for cost variations in providing health care to beneficiaries based on various risk factors, including health status. The goal of risk adjustment is to see that plans are properly reimbursed for the risk of the beneficiaries they enroll, including those with chronic conditions. The Centers for Medicare & Medicaid Services (CMS) uses the diagnosis codes submitted by Medicare Advantage plans for their enrollees’ medical conditions to determine enrollee risk scores. CMS conducts risk adjustment data validation or RADV audits to verify if the diagnosis codes submitted for payment by MA organizations are supported by the medical record documentation for enrollees.
The aim of the RADV audit is to identify and correct MA improper payments. An improper payment is one that should not have been made or that was made in an incorrect amount (such as overpayments and underpayments) under statutory and legally applicable requirements. According to a 2015 CMS financial report, up to 75 percent of estimated overpayments to Medicare Advantage (MA) plans were related to deficiencies in the provider documentation needed to support the patient’s risk score through the reported diagnosis codes. If the RADV audit finds that the patient’s medical record does not support the diagnosis, CMS will demand a refund from the MA plan, which in turn, will most likely seek compensation from the provider.
With CMS proposing to expand the scope and scale of RADV audits to reduce payment errors, providers need to ensure that their documentation complies with the necessary standards. Adhering to the following documentation guidelines will promote compliance with CMS data validation requirements:
- The medical record documentation should be legible.
- The record should be from the correct calendar year for the payment year being audited (i.e., for audits of 2015 payments, validating records should be from calendar year 2014).
- CMS accepts only Medical record documentation from a face-to-face encounter (between a patient and physician/provider) as appropriate. So the condition or findings must be discussed and notated in the patient face-to-face encounter.
- The date of service should be present for the face to face visit.
- Patient’s name and date should appear on every page of the medical record.
- The physician’s signature and credentials should be included on each patient encounter and electronic signature should be authenticated by the responsible provider.
- Medical record documentation is supported by accurate ICD-10 codes.
- Coding of all documented conditions that coexist at the time of the visit, and require or impact patient treatment. Use history codes if the historical condition has an impact on current care or influences treatment.
- Coding and reporting of chronic conditions treated on an ongoing basis as many times as the patient receives treatment and care for the condition(s).
- State specificity of condition – specify if the condition is chronic, major, recurrent and type, for e.g., chronic renal insufficiency, major depression, and chronic hepatitis.
- Link related conditions in the documentation – for example, diabetes with renal manifestations. Additional diagnosis codes should be used to identify the manifestation.
- Use modifiers along with CPT codes give extra information about how, where and why a procedure was performed.
Points to note:
- Do not use stamped signature stamps as they are not accepted
- Do not use typed signatures unless they are authenticated by the physician
- Do not report unacceptable types of diagnoses, for instance, exclude “probable”, “suspected”, “questionable”, “rule out” or “working” diagnoses
- Do not code conditions that were previously treated/no longer exist
- If disease conditions are not validated, it cannot be coded as linked
Payers can ensure that submission of medical record documentation for RADV complies with all CMS instructions with professional RADV audit services and medical record coding services.
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