In every healthcare environment, the medical record is foundational to all aspects of care and key to compliance and revenues. In capitated environments, payment models are supported by carefully documenting and coding the complexities of conditions affecting patient care. The diagnosis coding system is complex and easily misunderstood. Providers are usually not trained in ICD-10 coding, and often use extensive time and effort assigning and verifying codes. Time constraints and lack of training frequently lead to miscoding, which results in programs suffering from threats to both compliance and revenue.
Coding and Auditing Services
With Core Services Audits, our highly-experienced staff reviews internal medical records to validate that submitted diagnoses codes are supported by documentation, and verify that all documented diagnoses are submitted. The audit results report provides a rich source of feedback to providers and management teams, including:
- Rationale and suggested action for each diagnosis outcome.
- Detailed reports that allow easy tracking and trending.
This service validates compliance, and can be integrated into QAPI programs as evidence of internal auditing and monitoring processes supporting Part D requirements.
*An audit can be a stand-alone service, but is included in our Core Risk Adjustment Retainer Plan for best results.
Capstone has many years of experience working with organizations to help optimize documentation and coding for risk adjustment. RN coders on our team assist with documentation improvement through audits as described above. Our coding services include concurrent coding of the records prior to data submission. This service involves reviewing the medical record notes as soon as possible after the encounter to assist the provider in timely and complete documentation and confirming the ICD-10 codes appropriate to the documentation. This service receives very high reviews by providing:
- Quick feedback to providers for documentation improvement
- Less provider time and effort needed for addenda
- Increased diagnosis code completeness resulting in higher HCC capture
- Confidence that codes are valid and supported for compliance requirements
We have experience with most of the EMR systems used in PACE programs and work third-party administrators as needed to ensure timely submission of diagnosis codes for RAPS files. This service is priced on a per member/per month basis, either stand alone or bundled with other services
With passage of the Accountable Care Act, the federal government has increased efforts to ensure accurate payments and to recover overpayments. Risk Adjustment Data Validation (RADV) audits are done by CMS and also the OIG to determine whether HCCS generated by the diagnosis codes submitted by PACE and Medicare Advantage organizations can be validated in medical record documentation. Diagnoses that cannot be validated contribute to a payment error rate. Our Simulated RADV Audit service mimics CMS’s methodology and provides clients with a realistic view of their compliance level in regard to documentation, coding, and data submission.
The process is straight-forward and can be set-up as a single audit or annually. Once we obtain the necessary data files, our software generates the sample for auditing using the three-tier method CMS uses. We provide a complete list of HCCs to be validated with worksheets and dates of service to facilitate the collection of the medical records. Clients may electronically submit up to five supporting medical records for each CMS-HCC being validated.
The record review is done by Capstone coders and recorded in Capstone’s database, with each diagnosis being designated as submitted/valid, submitted/invalid, or not submitted/valid. Capstone will calculate the payment error based on the validation results. The extrapolated payment error estimate will be calculated according to published methodology.
Capstone will provide the following reports within 90 days of receiving all records:
- Report of all reviews and outcomes of all diagnoses audited, including diagnoses that need to be submitted or redacted.
- Payment error estimate and extrapolated payment recovery estimate
- Recommendations for further actions.
Simulated RADV audits are priced based on program census, which determines the sample of records selected for review.
PACE Organizations sometimes find that circumstances conspire such that all diagnosis data does not get completely or accurately submitted. This situation invariably leads to sub-optimal revenues and tends to repeat itself. Capstone can help by performing retrospective reviews of records to identify documented diagnoses that were not submitted for RAPS.
Medicare timely filing requirements allow for data to be submitted up to thirteen months after the close of the data period. This means, for example, documentation for dates of service in 2018, which provide diagnosis data for Payment Year 2019 may have diagnoses that can be submitted for RAPS purposes until January 31, 2020. These codes will be incorporated into the final model run and generate a reconciliation payment mid-2020 for all of 2019.
A retrospective review may be considered if a PACE organization discovers that a significant proportion of diagnoses may not have been submitted for any reason. Our review will identify submitted diagnoses and provide the PACE organization a file of valid diagnosis codes and visit dates that may be used to correct the missing data. We will provide an impact analysis to determine what additional revenues are generated.
This service is priced as a contingency model, with the PACE organization keeping at least 80% of all recovered revenue.
Capstone is proud to introduce what we believe is the most helpful process available for a PACE organization looking to optimize documentation improvement, compliance, and revenue. Our Prospective Review takes advantage of the clinical expertise of RN coders to review clinical documentation for participants and develop a preliminary problem/diagnosis list for providers, prior to performing comprehensive assessments.
The coders review previous encounters, labs, radiology, medication lists, consult reports and proprietary analytics in order to provide a detailed list of all diagnoses and ICD codes along with a rationale for each potential diagnosis. Providers use this list to aid in complete and accurate documentation and coding. ProDx is limited to annual and semi-annual primary care assessments.
Experience with this service model has found it to be highly effective for identifying and documenting commonly missed diagnoses and codes. Pricing is based as per member/per month or per review, and we offer a discount if bundled with other services.
