CMS Issues RADV Blueprint for Handling Flawed Documentation

New CMS document features gems that fill risk adjustment voids for coding rules.

Coders love rules. In risk adjustment coding, we live by the Official Guidelines for Coding and Reporting, the ICD-10-CM conventions for code lookup, and the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS. Too often, though, we run into situations in which there are no rules, or when guidance is sketchy. Because diagnoses translate into revenue in risk adjustment, employers usually develop and maintain internal coding policies to provide rules where none exist. And they long for official advice from the Centers for Medicare & Medicaid Services (CMS).

Without fanfare, CMS published a 56-page document entitled Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance late last year. Within this painstaking document are some gems that fill risk adjustment voids for coding rules. For example, Review Guidance offers the following advice regarding problem lists within a medical record:

This simple entry packs quite a punch! We have all been taught that problem lists are not acceptable sources for risk adjustment coding, yet CMS instructs auditors to evaluate a diagnosis from a problem list on a case-by-case basis, even if the list is auto-populated within an EMR.

According to the Review Guidance, problem list diagnoses are evaluated based on “chronicity and support in the full medical record, such as history, medications, and final assessment.” By chronicity, CMS is differentiating between chronic, incurable conditions (e.g., diabetes, multiple sclerosis) and acute conditions (e.g., pneumonia, sepsis). CMS also directs auditors to seek out information elsewhere in the record that may validate a problem list diagnosis. This might include a medication (e.g., “metformin” for diabetes) or history of present illness (e.g., “patient’s blood sugars are in control despite cellulitis”).

This new guidance on problem lists has some organizations scratching their heads on whether coders should begin reporting these problem-list diagnoses. That’s an organizational choice, because while revenues may be raised by including these diagnoses, the possibility of negative outcomes during an RADV also rise. Remember, CMS auditors are given discretion on whether to accept these problem list diagnoses. Normally, these would be reported only as last-ditch efforts to validate a reported code in an RADV audit.

The Review Guidance also clarifies how auditors should treat codes substituted for diagnosis narratives in documentation:

Thus, if “E10.65 Diabetes” is documented, the coder abstracts using the narrative (“Diabetes”) rather than from the diagnosis represented by the code (type 1 diabetes with hyperglycemia). Correct reporting for “E10.65 Diabetes” is E11.9, Type 2 diabetes mellitus without complication.

A solid CDI program is a better approach to under-documentation.

The entire Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance can be accessed at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation-Program/Other-Content-Types/RADV-Docs/Coders-Guidance.pdf.

Program Note

Listen to Sheri Poe Bernard report on this subject during this morning’s Talk Ten Tuesdays broadcast, 10-10:30 a.m. EST.

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