Risk Adjustment Data Validation (RADV) Guidelines for Medical Record Documentation

Risk Adjustment Data Validation (RADV) Guidelines for Medical Record Documentation

  • 27 Jun 8
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Written by: Dr. Richard Schamp, CEO

The Centers for Medicare and Medicaid Services (CMS) perform risk adjustment data validation audits on patients’ medical records. Risk adjustment data validation (RADV) is the process of verifying diagnosis codes submitted for payment are supported by medical record documentation. The purpose is to ensure risk adjusted payment integrity and accuracy.  CMS has announced its intention to increase auditing activity consistent with an emphasis to reduce payment errors.

Signs your plan may be at risk for a RADV:

  • Large change in year-over-year risk scores – CMS will focus on plans with big increases in score to ensure it is correct
  • Very few delete records – if you are not doing deletes, you are reviewing your own submissions for accuracy and correcting errors
  • Other corrective actions – has your plan been reviewed for something else? It may increase your likelihood of audit as CMS sees you as a risk.

At Capstone Performance Systems we have some specific documentation guidelines to follow to promote compliance with CMS data validation.

  • Medical record documentation must be legible.
  • For risk adjustment data validation purposes, CMS will only consider medical record documentation from a face-to-face encounter (between a patient and physician/provider). [Note: CMS does not accept initials and a date on a lab report as adequate documentation. They also do not accept a copy of a note in the file where lab results were mailed to a patient. The condition or findings must be discussed and notated in the patient face-to-face encounter for CMS to accept this as appropriate documentation. Superbills or encounter forms and problem lists are also unacceptable types of medical record documentation to validate an ICD-9 CM code.]
  • Physician’s signature and their credentials must be included on each patient encounter, the following is acceptable: Mary C. Smith, MD or MCS, MD.  [Note: credentials must be either next to the provider’s signature or pre-printed with the provider’s name on the practice’s stationery.]
  • Electronic Signature – requires authentication by the responsible provider (for example, but not limited to “Approved by”; “Signed by”; or “Electronically signed by”. They must also be password protected and used exclusively by the individual provider.) 
  • Signature Stamp – Stamped signatures are no longer acceptable for provider documentation effective January 1, 2009.
  • Typed Signature – is unacceptable unless it is authenticated by the physician/provider. 
  • Patient’s name must appear on every page of the medical record and all entries/encounters must be dated.
  • Records must be coded in accordance with the ICD-9-CM Guidelines for Coding and Reporting. Medical record documentation must support the code selected and substantiate that the proper coding guidelines were followed. Documentation must support that condition was addressed such as status of condition, lab values, PE, symptoms, education.  Ordering labs and medications does not validate the diagnosis.
  • Code all documented conditions that coexist at the time of the visit, and require or affect patient care treatment or management.  Do not code conditions that were previously treated and no longer exist.  However, history codes may be used if the historical condition or family history has an impact on current care or influences treatment. Do not document a diagnosis as “history of” for a condition that is acute or chronic still requiring management or treatment.
  • Chronic conditions treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). Address chronic conditions at least every 6 months.  Code all documented conditions that coexist at the time of the visit and require or affect patient treatment or management.  Even if the note states, “doing well with diabetic diet or continues to do home blood sugar monitoring,” CMS considers this notation as meeting their criteria.
  • Sign the medical record and make all notations timely. [Note: CMS expects records to be documented at the time of the visit.]  Addendums are acceptable in certain circumstances such as the following: Patient has visit for a mole removal. The pathology report is received several days after the office visit and confirms malignant melanoma. The physician reviews the findings, initials the report, and documents in the record the results and notification to the patient.  Since the removal of the mole was done during the office visit, the new code (for example,172.9) should be submitted with that date of service.
  • Unacceptable types of diagnoses.  “Probable”, “suspected”, “questionable”, “rule out” or “working” diagnoses cannot be reported to CMS as valid diagnoses by a physician or in the outpatient hospital setting.
  • Document specificity of condition.  Specify conditions as chronic, major, recurrent and type of condition such as chronic renal insufficiency, major depression, chronic hepatitis C, if the condition is chronic, major, or recurrent.
  • Linking diagnosis with manifestations.  When conditions are related, link them together in the documentation, for example, diabetes with peripheral vascular disease.  When linking conditions, include documentation to support both conditions.  Use additional diagnosis codes to identify manifestation.  If both conditions are not validated, it cannot be coded as linked.
  • Use V codes when appropriate.  Document health status conditions in notes (amputation status, transplant status, dialysis, HIV status, and artificial opening such as colostomy and ileostomy).

For more information about RADV please contact us.


*The information presented here complies with accepted coding practices and guidelines as defined in the ICD-9-CM coding book. It is the responsibility of the healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM code(s) according to the official coding  guidelines.

*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.