How Would Your Organization Defend This Auditing Accusation?

May 23rd, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Categories:   Office of Inspector General (OIG)   Risk Adjustment   

In May 2021, the Office of Inspector General (OIG) published their report of their audit findings from a risk adjustment contract with Anthem titled,

Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Anthem Community Insurance Company, Inc., (Contract H3655) Submitted to CMS.

The OIG used an independent audit contractor to perform the audit and reported the findings along with a demand for repayment of the monies. Anthem responded with their own audit findings and the full report is available to review by clicking HERE. For the remainder of this report we will only refer to the OIG's independent audit contractor as just the OIG.

What the OIG Discovered

The OIG stated that for one enrollee year, the independent contract auditors (ICAs) reviewed medical records for claims reporting major depressive disorder (MDD) to determine if the documentation was from a face-to-face encounter and supported the diagnosis. For reference, the following codes are used to report major depressive disorder, either for a single episode or a recurrent episode. The information in the second column of the table is the correlating HCC for CMS and HHS plans. Those marked with a 0 indicate the code does not correlate with an HCC or risk adjust for the HHS plans.

F32.0 Major depressive disorder, single episode, mild CMS-59/HHS-0
F32.1 Major depressive disorder, single episode, moderate CMS-59/HHS-0
F32.2 Major depressive disorder, single episode, severe without psychotic features CMS-59/HHS-88
F32.3 Major depressive disorder, single episode, with psychotic features CMS-59/HHS-88
F32.4 Major depressive disorder, single episode, in partial remission CMS-59/HHS-0
F32.5 Major depressive disorder, single episode, in full remission CMS-59/HHS-0
F33.0 Major depressive disorder, recurrent, mild CMS-59/HHS-0
F33.1 Major depressive disorder, recurrent, moderate CMS-59/HHS-0
F33.2 Major depressive disorder, recurrent, severe without psychotic symptoms CMS-59/HHS-88
F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms CMS-59/HHS-88
F33.40 Major depressive disorder, recurrent, in remission, unspecified CMS-59/HHS-0
F33.41 Major depressive disorder, recurrent, in partial remission CMS-59/HHS-0
F33.42 Major depressive disorder, recurrent, in full remission CMS-59/HHS-0
F33.8  Other recurrent depressive disorders CMS-59/HHS-0
F33.9  Major depressive disorder, recurrent, unspecified CMS-59/HHS-0

The OIG's report indicates that for one enrollee year, the provider's documentation did not support the HCC for MDD because the diagnosis documented was "mild depression," which does not map to an HCC

Coding Tip: "F32.A Depression, unspecified" was newly added to ICD-10-CM with an effective date of October 1, 2021 and does not risk adjust.

Anthem's review of these findings was interesting and teaches lessons to both physician's, risk adjustment payers, and coding/auditing staff alike. Anthem not only audited the OIG findings, but they also performed a comprehensive review of the medical record, which provided additional documentation to support the diagnosis of major depressive disorder, mild, (MDD) stating the following:

"OIG's independent medical review contractor has misinterpreted the medical record. The provider documented "mild depression," and in the context of the entire medical record and consistent with clinical diagnostic standards, the term "mild" should be read to modify major depressive disorder. The most widely accepted definitions of mental health conditions can be found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders V ("DSM-V"). The DSM-V states that major depressive disorder can be either mild, moderate, or severe—there is no separate diagnosis in the DSM-V for "mild depression."

Anthem stated the medical record shows the patient was suffering from symptoms of depressed mood, difficulty sleeping, and fatigue, and indicated in the medical record that these symptoms were affecting the patient's daily functioning. The provider also documented a recommendation that the patient "resume social interaction."

Anthem also went on to clarify the code descriptions for major depressive disorder, which contain levels of severity such as mild, moderate, and severe, whereas there are no general depression codes with a severity rating that can be explained by the symptoms of major depressive disorder.

Often auditors are looking at the medical record with the single goal of finding an error or defending an error instead of actually reviewing the record at face value and comparing it with the ICD-10-CM code descriptions. Little nuggets of information like this can help payers and providers alike stay on top of documentation and coding policies to avoid painful audits like these. Take the time to review the full report and find out what other lessons can be learned in the pursuit of quality care and proper reimbursement for services.


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