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.

###

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)

What’s Going on with the COVID Vaccines Now?
May 4th, 2023 - Wyn Staheli
Keeping up with the changes to the COVID vaccines has certainly been a rollercoaster ride and we now have two new twists to this exciting ride. Buckle up and let’s look at how this changes things.
Reporting Modifiers 76 and 77 with Confidence
April 18th, 2023 - Aimee Wilcox
Modifiers are used to indicate that a procedure has been altered by a specific circumstance, so you can imagine how often modifiers are reported when billing medical services. There are modifiers that should only be applied to Evaluation and Management (E/M) service codes and modifiers used only with procedure codes. Modifiers 76 and 77 are used to identify times when either the same provider or a different provider repeated the same service on the same day and misapplication of these modifiers can result in claim denials.
Five Documentation Habits Providers Can Use Implement to Improve Evaluation & Management (E/M) Scoring
April 11th, 2023 - Aimee Wilcox
Provider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.
Second Quarter 2023 Updates are Different This Year
April 6th, 2023 - Wyn Staheli
The second quarter of 2023 is NOT business as usual so it is important to pay attention to ensure that organizational processes and training take place to avoid mistakes. Not only have ICD-10-CM coding updates been added to the usual code set updates (e.g., CPT, HCPCS, ICD-10-PCS), but the end of the COVID-19 Public Health Emergency will bring about changes that will also take place during the quarter (but not on April 1, 2023.
7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth Fraud
March 28th, 2023 - Aimee Wilcox
A recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?
MUEs and Bilateral Indicators
March 23rd, 2023 - Chris Woolstenhulme
MUEs are used by Medicare to help reduce improper payments for Part B claims. This article will address the use of the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) and how they are used by CMS.
It is True the COVID-19 PHE is Expiring
March 16th, 2023 - Raquel Shumway
The COVID-19 PHE is Expiring, according to HHS. What is changing and what is staying the same? Make sure you understand how it will affect your practice and your patients.



Home About Terms Privacy

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

Copyright © 2000-2023 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association