Top 10 Medicare Risk Adjustment Coding Errors


MazeMedicare Advantage (MA) reimbursement can trip you up in ways you didn’t expect. If you are seeing MA patients, be mindful of opportunities and pitfalls.

MA health plans are reimbursed based on beneficiaries’ chronic conditions. Submitting an inaccurate diagnosis, or a diagnosis resulting in a different hierarchical condition category (HCC), is a compliance risk. Any change in the HCC could mean you are receiving too much or too little revenue. Either way, the code would not be validated and would be considered discrepant.

There are opportunities for you to capture a more appropriate HCC code. Consider this list of the top 10 coding errors for risk adjustment:

  1. The record does not contain a legible signature with credential.
  2. The electronic health record (EHR) was unauthenticated (not electronically signed).
  3. The highest degree of specificity was not assigned the most precise ICD-9-CM code to fully explain the narrative description of the symptom or diagnosis in the medical chart.
  4. A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record. If the record indicates depression, NOS (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter document is major depression (296.20 Major depressive affective disorder, single episode, unspecified), these codes do not match; they map to a different HCC category. The diagnosis code and the description should mirror each other.
  5. Documentation does not indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
  6. Status of cancer is unclear. Treatment is not documented.
  7. Chronic conditions, such as hepatitis or renal insufficiency, are not documented as chronic.
  8. Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific type of arrhythmia).
  9. Chronic conditions or status codes aren’t documented in the medical record at least once per year.
  10. A link or cause relationship is missing for a diabetic complication, or there is a failure to report a mandatory manifestation code.

Regardless of where you find shortcomings in your facility, you should consider ways to improve clinical documentation. Develop a compliance plan and implement prospective and retrospective, internal and external chart reviews with ongoing monitoring and feedback. Be sure to review records based on official coding guidelines.


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18 Responses to “Top 10 Medicare Risk Adjustment Coding Errors”

  1. Lynn Wojnowski says:

    I would be interested in hearing how others have worked to improve their clinical documentation to support RAF. We have an EMR, and looking for workflow changes to improve our RAF coding.

  2. Maryann Palmeter says:

    I would be interested in the source for this top 10 list. I would like to distribute to my physicians but they will want to know the source of the data.

  3. Donna Kober says:

    I would be interested in knowing where I can find documentation that supports the MEAT concept. I would love to present this to physicians, but as the above writer indicated, they are going to want to know the source of the data.

  4. Tammy Moss-Harris says:

    I work for a RA focused company and we are transitiiioning our coders into CDIS for documentation review and edcucation for the providers with query tracking and feedback, which will also help the providers tremendously with ICD-10. As far as the information souuce above, it is all documented in the CMS manual for RADV.

  5. TAT says:

    Good documentation should be encouragement to complete for the clinical professional. However, wiht this said the lines of communciation needs to be open to inform them of this fact. I do not know if the QA managers at medical facilities or the coders can gentle nudge the clinical doctors and allied health in this direction.

  6. Judy Marino says:

    Regarding all if the comments already submitted
    All of Carol Olsons comments are out of the CMS 2008 HCC Manual available on the CMS website.
    MEAT is also used by CMS for E&M as part of MDM
    The only thing that makes providers change is $$$. I worked for an IPA that incentivised the providers and they were very happy to do whatever we asked of them. One of my Docs told me “I used to wait for my diabetics to tell me they had numbness in their feet, now I ask” and she felt like it made her a better doctor.
    If you use queries make sure you understand CMS guidelines on queries so you don’t end up with any “issues” there. Queries and feedback is the only way to get from point A to point B in HCC
    ICE RADAR (considered the standard in the industry) website has Provider training material that you can download if you are interested in that. I was on the committee that put it all together a couple of years ago and the guidelines have not changed since 2008.

  7. Mary Ann Moosman says:

    If physicians are not taking the initiative to create EHR templates that can meet business needs such as clinical content, coding and billing requirements, patient safety, regulatory guidelines while improving functionality and work flow, we may just be beating our head against a wall. So many practitioners use the templates that come standard with the software and progress notes are non-compliant. With template improvement and addition of features like free text and features that block contradictions, documentation would improve. We don’t need more information, just accurate information.

  8. Dr. Todd Husty says:

    Over 20 years ago we started auditing DRG coding, a risk-adjusted reimbursement system. Along came HCC’s, a much more documentation dependent risk-adjusted system which, from my perspective is a much better system because it looks at All of the risk based diagnoses that a patient has. Over 20 years ago we started promoting the concept that physician documentation is the
    ” center of the reimbursement universe”. Not that many people listened, until recently. Documentation improvement has flourished, but from my observations is usually unsuccessful… I can back that up. Bottom line, it’s hard to get physicians to change. They (we) want proof, see Donna’s comments above (we did a large audit for Donna’s previous employer). But they don’t learn from a few simple lectures. They, we, need constant attention… You probably recognize that. They need to be brought into the fold. Incentives help a lot it’s so do constant queries (see Judy’s comments above… That’s why I hired her… She is successful).

    My talk at AHIMA 2012 was about Comprehensive Clinical Documentation Improvement. We had the chance to audit the company who had adopted that process of constant auditing and queries. The important part is that they didn’t do it because of my company, they had their own original thought and implemented it. Their outcomes have been well beyond national norms. It was very refreshing to see that our idea, which was also their idea, was successful while others have not been able to find success. I am not trying to advertise, although obviously we like business. I’m trying to support true documentation improvement that results in more accurate coding. You can do this on your own, or with some help, or with a lot of help. You have to figure out what’s right for you and your organization… And what you can talk them into. There are track records of improvement in physician documentation. I’ve always said, if doctors documented specifically and sufficiently, coding would be pretty easy. But you will never work yourself out of a job because, as Judy told me with a great amount of respect, “you are doctors after all”.

    Incentives, physician education, and ongoing physician education through queries. If you make it happen, you become a hero. Good luck.

  9. Kris says:

    Be careful of queries…if the query is not handled properly and the documentation is not entered into the chart note moving forward (cannot be back dated)…you will have a paper with diagnostic statements that are not supported by chart notes. The physicians MUST document all diagnostic statements in progress notes during face-to-face encounters. Due to the large failure of queries being handled correctly and documentation not being done properly, we no longer use this means of capturing data.

    We use a method of education to the physician done one-on-one with specific examples. Both prospective and retrospective reviews as well. We have seen huge successes in getting rid of the query. Plus it’s one less paper for the doc to review.

  10. Tina says:

    Does anyone have advice for home visits to collect HCC data? The home visit and form present unique challenges when looking for data to support any HCC that has been captured. Any stories, ideas, or tips for training providers to correctly document the forms on the home visits to support dx coding.

  11. Doug Thrasher, D.O. says:

    Regarding the comment above reccomending doctors modify their templates vs using what comes standard..often we are told by IT that templates cannot be modified, or it is such a low priority that 6 to 12 month timelines ar projected Most recently we have been told that our EMR will no longer be supported within 12 mos…sigh…!

  12. Jennifer Gehen says:

    Home visits to collect HCC data? Does anyone have any tips for training providers to correctly document the forms on the home visits to support dx coding?

  13. Nancy Keenan says:

    Can anyone speak to #10 as to what is acceptable to Medicare in a RAD-V audit as linking the manifestation to diabetes in an EMR? One large insurance company is not allowing the following:

    1. Diabetes with Neurological manifestation 250.60
    2. Gastroparesis 536.3

    They are not allowing the above because it doesn’t state diabetic gastroparesis, Gastroparesis secondary to Diabetes, or Diabetes with Gastroparesis (which can be free texted or linked in the HPI in some EMR’s). The same goes for 250.70 and 443.9 or 443.81. If anyone can provide any insight on this issue, please let me know.


  14. Lois M says:

    (In response to Nancy’s comment) The codes need to be linked conclusively. Advise your docs to clearly state the manifestation is due to diabetes.

  15. Johnna Floyd, CPMA, CPCO, CPC, CPC-P says:

    I have worked in MRA for over 3 years now, with a MA payer and now with an IPA. The easiest way to link DM to a manifestation is TWO letters – Change DiabetES to DiabetIC – Diabetes with Neurological manifestations with Neuropathy now becomes Diabetic Neuropathy. Less words for the Dr. to write and less chance to miss the 2nd required code per the ICD-9. With EMR’s you should be able to setup the codes to where it will trigger the provider to pull the 2nd code.

  16. Marshall says:

    Hello. If you have medical students in your office can you get them involved in chart reviews for MRA coding or would this be unsavory? What would we need to teach them in order for them to conduct chart reviews effectively and efficiently?

  17. Lois M says:

    The information in the article above, siting 10 common ‘coding’ issues (numbers one and two are actually administrative issues with nothing to do with coding) can all be verified at the CMS website. Go to and search for: 2008 Risk Adjustment Data Technical Assistance for Medicare Advantage Organizations Participant Guide.
    Check out section 6: Diagnosis Codes and Risk Adjustment.
    Again, all ten of the issues in this article are important and need to be understood by both providers and coders. The Participant Guide addresses these issues.

  18. EnrollMyMedicare says:

    We are provides a best information for Washington Medicare Plans in USA.

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