Contract-level RADV audits can seem daunting, but with these tips they do not need to be overwhelming.
If you’re an HCC coder, there is no doubt you’ve heard of a Risk Adjustment Data Validation (RADV) audit. The Centers for Medicare & Medicaid Services (CMS) conducts various RADV audits, but this article focuses on lessons learned from Contract-Level RADV audits.
CMS selects a subset of Part C contracts for each annual RADV audit cycle to ensure that medical record documentation supports diagnoses submitted for risk adjustment.
The purpose of a contract-Level RADV is to identify discrepancies in payments by comparing RA diagnosis data that a Medicare Advantage organization (MAO) submits for payment against documentation in the medical record.
MAOs are selected for audit using pre-determined eligibility criteria and then CMS selects a random sample of enrollees for the audit. Once the enrollees have been selected, the MAO is required to submit medical records to support all CMS-Hierarchical Condition Categories (HCCs) in the sampled beneficiaries’ risk scores for the payment year.
Selected MAOs typically receive 25 weeks to request and obtain medical records, review those records for best representation of audited HCCs, prepare the chart into a pdf format file with coversheet identifying the HCCs, and submit to a secure system such as the Centralized Data Abstraction Tool (CDAT).
Here are seven tips for coders to prepare for Contract-Level RADV audits:
Be organized. There is a large amount of information that is involved in a RADV audit along with a fixed deadline set by CMS; being organized is key to success. Efficiently managing your time and using effective tools such as spreadsheets, databases, or coding software to capture and track pertinent information is essential to completing an audit successfully. Being organized will keep you on track and focused on the end goal.
Prioritize and retrieve the best charts. While it might be tempting to retrieve every chart that contains information for the plan year being audited, there is value in retrieving high priority charts first. This may include charts where the HCC was initially generated. Inpatient hospital charts are also a great source to find HCCs that need to be submitted for validation. Subsection 422.310(e) requires MA organizations, providers, and practitioners to submit a sample of medical records to validate risk adjustment data.
Know your coding guidelines. To avoid a discrepant finding for a medical record, CMS requires the documentation be:
- Coded according to the official conventions and instructions provided within ICD-9-CM, the ICD-9-CM Official Guidelines for Coding and Reporting*
- Follow the guidance provided in the, AHA Coding Clinic for ICD-9-CM, which is published quarterly by the American Hospital Association (AHA)
- Refer only to issue dates effective at the time of encounter
RADV audits are done retrospectively, which means there is no way to query a provider for clarification when encountering ambiguous documentation. Without the ability to query, we must turn to Coding Clinic such as Clinical Criteria and Code Assignment 4th quarter 2016, for guidance. The Coding Clinic is in reference to an official coding guideline that states, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”
Per Coding Clinic, “The guideline noted addresses coding, not clinical validation. It is appropriate for facilities to ensure that documentation is complete, accurate, and appropriately reflects the patient’s clinical conditions. Although ultimately related to the accuracy of the coding, clinical validation is a separate function from the coding process and clinical skill.”
Whether a physician uses the new clinical criteria for a diagnosis code, old criteria, his or her personal clinical judgment, or something else to decide a patient has a particular diagnosis (and document it as such), Coding Clinic says to report the code as long as it’s documented. Essentially: The code can be assigned regardless of how the physician arrived at the diagnosis.
Follow CMS rules for submissions. CMS has set clear guidance regarding requirements for submissions to avoid discrepant findings. Submissions must include the:
- Correct beneficiary as provided on the CMS RADV coversheet
- Acceptable risk adjustment provider type, source, and physician specialty providing the face-to-face encounter
- Dates of service within the data collection period under review
- Valid signatures and credentials
Entering information correctly on the coversheet will help avoid unnecessary denials. Remember, the administrative portion of this audit (e.g., patient name, acceptable provider type, date of service and signatures) is just as important as the coding itself.
Submit your best chart. RADV audits usually offer an option to receive early feedback. Best practice is to submit as many charts for validation as possible prior to this early feedback deadline. This strategy is invaluable to the MAO as it allows for the submission of additional charts if one is deemed to be discrepant prior to the final deadline.
A “best chart” is generally defined as: A face-to-face chart note that validates the requested HCC and validates an additional HCC not being audited, and contains all the necessary documentation elements (name, date of service, acceptable provider type, valid signature and credentials or an attestation if required). Consider submitting a chart note type that is specific to the diagnosis being validated (e.g., an oncology note for a cancer diagnosis).
Review results and make changes if necessary. As with any audit, it’s imperative to review results. This includes non-validated HCCs as well as validated results. It’s equally important to identify trends and patterns within those results. This allows the MAO to correct defects, if any are found, in its reporting to CMS for future audits.
Be prepared to appeal denials. Everyone is human and mistakes happen. That applies to the MAO as well as CMS auditors. Plan to thoroughly review all denials and appeal findings if you have documentation to support your arguments.
*RADV Medical Record Reviewer Guidance Version 2.0 is the most updated version (in effect as of 01/10/2020) for Contract-Level 15 RADV and applicable to dates of services that were still using ICD-9.
Sources: RADV Medical Record Reviewer Guidance Version 2.0 and AHA Coding Clinic
About the author
Melissa James CPC, CPMA, CRC, is employed by Wolters Kluwer as a senior consultant, health language.
She has more than 20 years of health care experience in coding, billing, physician and coder education, accounts receivable management, regulatory and compliance, and consulting.
She received her associates degree from Pueblo Community College. James is a member of the Pueblo local chapter in Pueblo, Colorado.