Know to Avoid Compliance Pitfalls and Support Accurate Cancer Dx Coding, Part 1
Look at these OIG audit results and learn. The Office of Inspector General (OIG) recently completed a series of audits for 10 diagnosis conditions identified as high risk for coding errors. Included in the 10 conditions were the following five active cancer diagnoses that the OIG audits found were not supported by the medical records: Further, the OIG reported that the unsupported active diagnosis codes submitted by the health plans reflected historical conditions, as there was no evidence of treatment or ongoing management. Consequently, the diagnosis codes reported resulted in overpayment to the health plans that submitted them as they did not meet federal requirements for payment. This article will examine the extent of the problem identified in the OIG findings and provide some foolproof tips to help you improve your documentation so that it complies with federal requirements. Then, in a follow-up article, we’ll expand upon one of the significant documentation problems identified in multiple OIG compliance audits: how to determine when documentation substantiates a cancer as active or historic. Take Note of These 2 OIG Compliance Audits Findings In two recent audits, the OIG found that “medical records did not support the diagnosis codes,” resulting in substantial overpayments of “at least $4.7 million … for 2018 and 2019” for UCare Minnesota and “at least $10.5 million … for 2017 and 2018” for Humana Health Benefit of Louisiana. Example 1: UCare Minnesota According to the Medicare Advantage Compliance Audit of Specific Diagnosis Codes That U-Care Minnesota ... Submitted to CMS (Centers for Medicare & Medicaid Services), “UCare incorrectly submitted diagnosis codes for lung cancer for 29 of 30 sampled enrollee years. Specifically, The OIG noted similar findings in the medical records of patients with breast, colon, prostate, and ovarian cancer. As a result of these errors, the diagnosis codes for the cancers were not validated, and over the 29 sampled enrollee years UCare received: Example 2: Humana Louisiana Similar to the UCare Minnesota findings, the OIG found incorrectly submitted diagnosis codes for all five cancers in its Medicare Advantage Compliance Audit of Specific Diagnosis Codes Humana Health Benefit of Louisiana… Submitted to CMS. In just one example: “An enrollee received one lung cancer diagnosis (that mapped to the HCC for Lung and all other Cancers) on only one claim during the service year but the cancer did not have surgical therapy, radiation treatments, or chemotherapy drug treatments administered within a 6-month period either before or after the diagnosis. In these instances, a diagnosis of history of lung cancer (which does not map to an HCC) typically should have been used.” As a result of these errors, the diagnosis codes for all the cancers were not validated, and Humana was required to perform the following actions: Then Apply the Lessons to Your Team Cancer care involves a multidisciplinary care team that includes many providers and coding professionals. However, diagnoses with specificity and support are often coded differently across care teams. Achieving a level of accuracy requires consistency across the entire care team, with a managing provider establishing a diagnosis and disease status, such as the oncologist overseeing the patient’s care. So, all providers involved in the patient’s care, including specialists, primary care physicians, and other treating practitioners, should document the same active cancer. Additionally, providers must work collaboratively with coders to ensure that diagnoses, particularly those used for risk adjustment, are clinically supported, thoroughly documented, and accurately coded, and that the diagnoses reflected in the medical record meet regulatory documentation expectations. When all members of the care team are aligned, the medical record more accurately reflects the patient’s condition, supports documentation and coding integrity, and reduces compliance risk. Additionally, clear and concise documentation assists physicians and other healthcare professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time. This means coders should: Queries, in particular, need to be carefully constructed. You should not create them solely to obtain support for reporting purses, but to remind the provider to review the documentation before documenting and to determine such things as whether to use an active or a historical code. At the same time, coders should not: Providers, meanwhile, should not: The importance of consistent, complete documentation in the medical record cannot be overemphasized. Clear and concise documentation facilitates quality patient care with better outcomes and timely provider payment for services rendered, keeping the revenue cycle flowing. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. When documentation lacks sufficient detail, specificity, clarity, or support, coders may be unable to assign the most accurate diagnosis codes. This can lead to coding errors and misrepresentation of the patient’s condition, in addition to reimbursement, data quality, and compliance risks. Ultimately, it is only the provider who is responsible to accurately connect the dots, not the coder, transcriptionist, or Artificial Intelligence (AI) system. Otherwise, the consequences will hit across the revenue cycle by triggering costly compliance and audit exposure. (In the second part of this series, we’ll look at how to use documentation to determine active and historic cancer codes.) Delly Parham, CRC, CPMA, CPC, Risk Adjustment Coder
