OIG Audit Reveals Diagnosis Reporting Problems Affecting Risk Adjustment Scoring

June 15th, 2023 - Wyn Staheli

The Office of the Inspector General (OIG) recently published their Spring 2023 Semiannual Report to Congress. This report contained some diagnoses reporting issues that all providers need to be aware of. They focused on several groups of diagnoses that they considered “High-Risk” for being miscoded. Several states were included in the report and the types of errors for all can be generally grouped into the following:

    1. No Hospital Claim Data: Certain conditions typically require facility services (i.e., hospital inpatient or outpatient) within a certain time frame (e.g., 60 days before or after). If there was not a corresponding hospital claim, they stated that the claims should have used either a “history of” diagnosis code (e.g., Z86.73) or a less severe manifestation of the disease code instead. Although the report itself did not name particular diagnoses codes, the descriptions they included were:
      • Acute stroke
      • Acute heart attack
      • Acute stroke and acute heart attack combination
    2. Medication Missing or Mis-matched: For certain conditions, it is expected that a patient will receive medication during the year to manage that condition. The following diagnoses were often either missing medication claims or had a different type of medication prescribed:
      • Major depressive disorder: Antidepressant medication should have been received by the patient. Also, be aware that there is now an unspecified code (F32.A) where there used to only be code F32.9 so be sure to review claims where code F32.9 was used to ensure that diagnostic criteria have been met.
      • Embolism: An anticoagulant medication is typically prescribed and would have been received by the patient. In these instances, a diagnosis of history of embolism (an indication that the provider is evaluating a prior acute embolism diagnosis that does not map to an HCC) typically should have been used.
      • Vascular claudication: The patient has received medication that is frequently dispensed for a diagnosis of neurogenic claudication — NOT vascular claudication. They also looked at the preceding 2 years to see what diagnoses were assigned during that time to look for incorrect coding not supported by the medical record.
    3. Missing Treatments: When a patient has a listed diagnosis of cancer (within a certain time period of that diagnosis) certain treatments during that year were expected to also be a part of the patient’s medical record, including but not limited to, surgical therapy, radiation treatments, or chemotherapy drug treatments. In these instances, a code for “history of cancer” that does not map to an HCC code (e.g., Z85.118, Z85.3, Z85.038) should typically have been used.
      • Lung cancer
      • Breast cancer
      • Colon cancer
      • Prostate cancer
    4. Potentially mis-keyed diagnosis codes: Some diagnosis codes can be easily transposed causing a data entry error and thus a wrong code is entered which then potentially maps to an incorrect HCC. One example in the report was “ICD-9 diagnosis code 250.00 (which maps to the HCC for Diabetes Without Complication) could be transposed as diagnosis code 205.00 (which maps to the HCC for Metastatic Cancer and Acute Leukemia and in this example would be invalidated).” Using data analytic tools, they compared all reported diagnoses codes for a patient and then used algorithms to flag those that might be a mis-match.

Now that we know which diagnoses are receiving increased scrutiny, take time to perform an internal audit to review claims with these diagnoses and ensure that they have been properly coded.


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)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Home About Terms Privacy

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

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association