05 Apr Off
By Richard Schamp, MD
In our last edition, I mentioned the burgeoning new competency for physicians and other clinical providers – clinical documentation excellence. Let’s delve further into some specifics around the kinds of competence required in a risk-adjusted payment model. CMS has a process to verify that diagnosis codes reported that are relevant for payments in the HCC (Hierarchical Condition Category) model are both correct and supported by the medical record documentation. This process is referred to as Risk Adjustment Data Validation (RADV). While most PACE organizations have not yet experienced a RADV audit, they must comply with all the requirements of documentation and coding, and assume that they will eventually face an audit.
I remember when my PACE organization had a full RADV audit. Going through that process completely reoriented how our PACE staff approached our documentation processes. At Capstone, we have worked with more than 80 PACE organizations, and we’ve seen common errors that put revenues at risk and sometimes present serious compliance issues. Here are some of the top issues:
- Incomplete notes. All encounter notes must be complete, with evidence of a history, examination, impression, and plan (or other similar format, such as SOAP). Simply listing diagnoses is not sufficient for coding and reporting – the documentation must indicate how the conditions affect patient care.
- Unsigned notes. All notes must have the rendering provider’s name, credential and signature. Notes may not be signed by a non-rendering provider.
- Non-reported diagnoses. CMS requires all relevant diagnoses (a “relevant” diagnosis is one that is included in the HCC or RxHCC payment models) to be reported at least once yearly. Not addressing, not coding, or not reporting a relevant diagnosis is non-compliant. Providers may sometimes overlook chronic stable conditions and not report them, e.g. amputation status, ostomy status, stable angina, stable heart failure, etc. Careful training and data review can avoid these dropped diagnoses and dropped payments, keeping your program compliant.
- Data leaks. We commonly find diagnoses in the medical record that are not reflected in the Risk Adjustment Processing System (RAPS) data. Since they do not file claims for most encounters, PACE organizations must have robust auditing and monitoring processes to find/fix/avoid data “leaks” between the medical record and RAPS.
- Over-diagnosing and over-coding. Obviously, upcoding or changing diagnoses to obtain higher payments without supporting evidence is fraudulent. Equally problematic, providers may inadvertently allow diagnoses to become memorialized in EMRs, reporting them when they no longer exist.
These situations and other common examples could generate findings in a RADV audit; all have straightforward remedies. Your providers need strong administrative support at the organizational level to develop best practices that avoid such missteps, as they are busy caring directly for patients. Capstone can support your organization in helping providers be more efficient and proficient at documentation excellence. Let us know how we can help.