Medicare Compliance & Reimbursement

If you’re interested in adding risk adjustment to your practice work plan, consider these four steps as you begin your program.

Step 1: Verify that you meet the Centers for Medicare & Medicaid Services’ (CMS’) documentation requirements such as the following:

• Signature: Records must contain a valid provider signature and credentials.
• Date: Each face-to-face date of service (DOS) stands alone for outpatient reporting.
• Patient name: Record must be for the correct member/patient.
• Acceptable encounter: Acceptable services should be billed and processed.

Step 2: Ensure you code all active medical conditions for each patient encounter and DOS from acceptable document sources by acceptable provider types. You should use documentation only from providers who are treating the patient.

Unacceptable provider types include: ambulance service providers; ambulatory surgery centers; anesthesiology assistants; independent diagnostic testing facilities; licensed practical nurses (LPNs); licensed vocational nurses (LVNs); mammography centers; medical assistants (MAs or CMAs); medical supply companies, nursing assistants (NAs or CANs); nutritionists; and radiologists.

Step 3: Avoid impermissible document sources. These include the following:

• Diagnosis related group (DRG) coding summaries
• Nursing notes
• All documents with DOS outside the data collection period
• Any document that was clearly not a face-to-face visit (with the exception of compliant telehealth encounters during the public health emergency)
• A diagnostic report that has not been interpreted, such as a lab report, radiology report, electrocardiogram (EKG), or Holter monitor report as standalone documents

Step 4: Stay on top of updates to ICD-10-CM codes and guidelines.