OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment

May 18th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Categories:   Audits/Auditing   Risk Adjustment    Coding  
0 Votes - Sign in to vote or comment.

According to an Office of The Inspector General Report, the Centers for Medicare & Medicaid Services (CMS) estimate that 9.5% of all payments to Medicare Advantage organizations are improper due to unsupported diagnoses submitted by the organizations themselves. 

Medicare Advantage Organizations (MAOs) receive funding based on ICD-10-CM reporting specific to the individual Medicare beneficiary enrolled in the MAO. A patient who is healthy will likely not require as many medical services as a beneficiary with poor health conditions or comorbidities. Barring unexpected injury or illness, healthier patients are less likely to experience hospital admissions, frequent physician encounters, or costly labs and/or imaging services during the same time period.

A beneficiary's risk factor is based on the sum of assigned hierarchical condition classification (HCC) codes assigned from identified diagnoses documented in the beneficiary's medical records from services rendered over a specific time period. Problems arise when the medical record documentation lacks the detail necessary to assign an ICD-10-CM code that accurately reflects the beneficiary's condition(s). 

Improper application of the ICD-10-CM Official Guidelines for Coding and Reporting may lead to an inaccurate code assignment or an incorrect risk adjustment factor score and subsequent over (or under) payment. While overpayment may lead to investigation and recoupment of funds, underpayment often results in the MAO paying the difference between funding for the beneficiary and any additional unanticipated healthcare costs. Hence, using the term "risk" in the title “Risk Adjustment” is appropriate. 

In their report titled “10 Key Compliance Priorities,” the OIG noted approximately 9.5% of all reported services do not have adequate documentation to support the assigned ICD-10-CM codes. The OIG recommended MAOs implement auditing strategies and resources, such as the data analytics employed by CMS, to assist in identifying suspected trends, outliers, and diagnoses that are more commonly plagued with inconsistent documentation or reporting practices; and suggests that by doing so, these organizations may benefit from the onslaught of possible risk adjustment audits headed their way.




###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Medicare Updates -- SNF, Neurostimulators, Ambulance Fee Schedule and more (2022-10-20)
October 27th, 2022 - CMS - MLNConnects
Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes...
2023 Evaluation & Management Updates Free Webinar
October 24th, 2022 - Aimee Wilcox
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
Are Leading Queries Prohibited by Law or Lore?
October 13th, 2022 - Erica E. Remer
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
2023 ICD-10-CM Guideline Changes
October 13th, 2022 - Chris Woolstenhulme
View the ICD-10-CM Guideline Changes for 2023 Chapter 19 (Injury, poisoning, and certain other consequences of external causes [S00-T88])The guidelines clarify that coders do not need to see a change in the patient’s condition to assign an underdosing code. According to the updated guidelines, “Documentation that the patient is taking less ...
Z Codes: Understanding Palliative Care and Related Z Codes
October 11th, 2022 - Gloryanne Bryant
Palliative care is often considered to be hospice and comfort care. Palliative care is sometimes used interchangeably with “comfort care” and then again sometimes with “hospice care.”  But these terms do have slightly different meanings and sometimes the meaning varies depending on who is stating it. The National...
2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Yes, You Have What It Takes To Lead Your Practice And Your Profession
September 20th, 2022 - Kem Tolliver
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association