Wiki HCC/RADV Dx documentation rules

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terribrown

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I have been assigned the task of finding a guideline or rule stating WHERE and HOW MANY TIMES a Dx has to be documented in the MR for documentation validation specifically for a RADV.

I have searched ICD-9, CPT, Risk-Adjustment participants guide, OIG Work Plan...and the list goes on and on. My problem is, I can only find generic statements such as 'the diagnosis must be based on clinical medical record documentation from a face-to-face encounter'. My Director wants back-up information of proper documentation to encourage our vendors to step up on the consistency and specificity.

Does anyone know of a ruling or guidance issued specifically for Risk-Adjustment validation as to what is the expected documentation of diagnoses used for payment? A QIO or other subcontractor is tasked to validate the MR in a RADV...so...if any of you work for...or have access to...training or P&Ps for QIOs/contractors used by Medicare for Dx validation, I would greatly appreciate any suggestions or comments that offer more than just "diagnosis must be documented".

Thank you!!
 
I think the most specific guidance from Medicare comes from the 2008 Participant Guide under Guidance for Problem Lists (7.2.4.3)

"Although the term 'problem list' is commonly used with regard to ambulatory medical record documentation, a univeral definition does not exist. The problem list is generally used by a coder to gain an overall clinical pictue of a patients condition(s). Problem lists are usually supported by other medical record documentation such as SOAP notes (subjective, objective, assessment, plan), progress notes, consultation notes, and diagnostic reports.
For CMS' risk adjustment data validation purposes, an acceptable problem list must be comprehensive and show evaluation and treatment for each conditon that relates to an ICD-9 code on the date of service, and it must be signed and dated by the physician or physician extender."

The way I interpret that guideline is that the documentation of the condition(s) would be in the progress note, just like any other documentation standard. The 2008 Participant Guide does note in section 6.5 that a SOAP note is an example of acceptable documentation.

As far as how many times the condition needs to be reported is supported by the ICD Guidelines for Outpatient Services, "Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management."

In terms of RADV the condition(s) needs to be reported at least once during each data collection period. The supporting documentation for that requirement will be found throughout Medicare's Risk Adjustment Methodology discussion. Since reimbursement is based on a previous year's submitted (documented) diagnoses, it is logically concluded that the documentation must include any conditions that were treated/evaluated.

I hope that helps or at least gets you started in the right direction. Good luck!

P.S. I have found Scanhealth to be a great resource, especially their HCC University.

http://www.scanhealthplan.com/hcc-university/
 
Thank you, Camille, for your comments and the link. I will dive into the material and search for guidance.

Our main issue we are trying to correct is that on a specialized assessment form, many of the providers are only documenting chronic conditions by linking that condition in the medication list. Yes, they are noting a current treatment plan and therefore stating that condition is ongoing and being monitored. However, we are trying to "encourage" them to be more consistent and show the condition is being addressed and assessed and not just documented as current. We are faced with opposition. Basically the only instruction we have is that chronic conditions are to be documented on a face-to-face visit at least once per payment year. The problem is there is no specificity as to how extensive that documentation needs to be.
 
HCC coding for Medicare Advantage plan

Hello,
I just saw your posts related to HCC coding. I would like to touch base with anyone who is working in Risk Adjustment or doing HCC coding. I am relatively new to HCC coding, working at a Medicare Advantage Plan in the midwest. I am working as a revenue management educator, in a department comprised of myself, 2 coder/auditors, my manager and an IT/data specialist. My role is to develop education for our affiliated providers and coders. I am very interested in developing a peer network with others who are working in this area. I would like to identify valid and reliable resources (CMS, SCAN health, etc.) and to hear any tips/ideas you have for providing education about HCC's. I would also like to have someone who works in a similar capacity to ask questions. I am definitely be interested in networking with any groups that exist.

A resource not mentioned previously that I came across is Industry Collaboration Effort(ICE). Their RADAR team is related to risk adjustment. I have only listened in on a few calls but have found it helpful. They also have some educational materials available on their website.

Thanks for taking the time to read my message.
 
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