new medicare advantage rules 11/1/2018


Livermore, CA
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I'm curious as to what other's reactions are to the new MA RADV auditing rule proposed on November 1, 2018. What do you believe it means to compliance professionals and how does this fit into the existing structure for the MA program as you already understand it. What do you think it means and how will be applied in the providers’ facilities. Here's a link to the proposed rule in the Federal Register:
54982 Federal Register / Vol. 83, No. 212 / Thursday, November 1, 2018 / Proposed Rules DEPARTMENT O…


Lithonia, GA
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IMHO the RADV Risk Adjustment Data Validation Audit

I think when provider's office get the request for medical record regarding a patient, notes need to be sent. Most physicians are pretty good with documentation. I think some medical coders do not list all dx. codes given from the provider's documentation in the outpatient setting and put Z codes as first which are not first lsited Z dx codes. This is a problem. CMS 1500 or UB90 claims and documentation for the days treatment may not match exactly. Or if missing dx. codes on bill format when on documentation. If this is the case....a payback will be necessary. I know with inpatient HCC only list 2 diagnosis codes per some hospital policies but also have the differ MD specialty physician billing for similar disease at same time.

Outpatient claim should list all diagnosis codes in proper sequence to match doctor's notation on the treatment day. Docs using unspecific dx. codes when documentation supports better detailed dx codes need to be watched and corrected by medical coders. RADV will just mean another method of honing in on documentation and billing claims should match. If they do not may have to send funds back.

Normally most docs do adequate documentation however superbills or check off medical record are not proper documentation to be used for coding. Also unsigned medical records just listing a name when really a doc's signature is required.

Medicare has always asked for medical records on their patients so this is really nothing new. Plus certain CPT codes and certain modifiers must submit medical records of the visit. So what is your view? It has always been medical documentation match CPT and dx. codes billed.

Lady T