OIG to Audit Risk Adjustment Coding

Consistent with previous reporting, the Office of Inspector General (OIG) has added to its 2020 Work Plan a targeted audit of Medicare Advantage (MA) programs for risk adjustment diagnosis codes.

This is not the first time federal agency has targeted risk adjustment data. The OIG stated back in 2017, “We will review the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS’s risk score calculations and determine whether the diagnoses submitted complied with Federal requirements.”

What’s at Risk

The OIG estimates that payments to Medicare Advantage organizations have been overpaid by about 9.5% because of over-reporting higher risk-adjusted diagnoses than what is documented in the charts by providers. The OIG has determined that the over-reporting is limited to a list of targeted diagnosis codes, and the audit will be limited to these targeted diagnosis codes. The OIG does not indicate in the Work Plan which diagnoses will be included in the targeted audit.

Put Your Guard Up

There are several tools MRA auditors use to assess documentation. Two popular ones are MEAT and TAMPER. Read more about these tools in the article “Assess Documentation to Validate Risk Adjustment Coding.” (Baron, Sept. 2019)

Resources:

42 CFR § 422.310(b)

SSA §§ 1853(a)(1)(C) and (a)(3) 

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Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

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