The Center for Medicare & Medicaid Services (CMS) has released an updated version of its contract-level risk adjustment data validation (RADV) medical record reviewer guidance that went into effect as of March 20.
The guidance focuses on apparent documentation issues with RADV submissions used to confirm audited CMS-Hierarchical Condition Categories (HCC). These issues could impact the validity of the medical record and may result in an error under the RADV medical record review process, which will lead to a discrepancy for the audited CMS-HCC findings. CMS will only use RADV coding results from valid medical record submissions to substantiate payment.
CMS has organized the guidance by tables that address the validity of medical record submission and attestations regarding enrollee name, signature, credentials, date of service, provider type, and other documentation issues. Note, CMS does not provide advice for specific diagnosis coding in the guidance. For that information, see the ICD-9-CM Official Guidelines for Coding and Reporting. Although organizations currently follow ICD-10 guidelines, RADV auditors are still conducting RADV audits for calendar year 2014, which involve dates of service from 2013 when the industry used ICD-9-CM codes.