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Thread: Potential Ethical Issue Medicare Risk Adjustment

  1. #1

    Exclamation Potential Ethical Issue Medicare Risk Adjustment

    AAPC: Back to School
    I am a Medicare Risk Adjustment Coder. We review medical records for diagnosis codes. Presently, I am performing quality assurance reviews on my co-workers code choices. If I reject their choices, the records go to my supervisor for a 3rd review. When this process is completed, the codes are forwarded to CMS where a Hierarchical Condition Category (HCC) score is established for the patient. The insurance company for which I am employed, is then paid by CMS for the care of our member based on the derived score. The problem I am facing is that, in reviewing the codes, I am often finding that my coworkers are not choosing the correct 4th and 5th digit for the code or are choosing a potentially incorrect diagnosis entirely. It has been suggested that unless these errors effect an HCC, and thereby effect the eventual care score for the member, I should not be marking these as errors, or changing the codes to those that are correct, in an effort to keep the process moving and decrease the number of records to be reviewed by the supervisor. I feel that this is ethically incorrect as it is causing me to accept what I feel is a known incorrect diagnosis code.

    Hoping someone might have some input into what they feel about the situation. Thanks so much.

  2. #2
    Join Date
    Apr 2007
    Tacoma, WA


    I agree with you. It is ethically incorrect to not code to the fullest possible degree. Are these co-workers also cerified coders? Has your supervisor told you to let the errors that are not HCC, slide? If so then this has become a compliance issue.

  3. #3

    Default Potential Ethical Issue

    It seems there are really two issues here

    1- Your co workers are not coding correctly. 4th and 5th digits are not voluntary. This is a company issue and should be dealt with thru the proper channels there.

    2- How can an incorrectly coded encounter not effect the work you are doing? If you paid a claim with an incorrect diagnosis, it's needs to be reviewed and appropriately accounted for.

    Perhaps you need to have two different types of issues that need to be reviewed. One for coding supervisor and co worker to review for incorrect coding. This one can be returned to you when it is properly coded. Then you could have another type of issues for supervisor review that has direct bearing on your Risk Adjustment.

    Keep up the good work!!!!!

  4. #4


    I do exactly the same job as you. And many times I see different 5th digit than another coder. True, many times a 5th digit won't change the HCC, but sometimes it does. Example: carotid artery stenosis without mention of cerebral infarct 433.10 is only RX HCC102 while 438.11 (with mention of cerebral infarct) is HCC96/RX HCC102 . Huge monetary difference! So...when I am a second reviewer of a peer's entries, I mark the code I found and make a note in our comment column of the spreadsheet to explain my code. While DM2 not stated as uncontrolled for 250.00 is the same HCC as DM2 uncontrolled 250.02, your supervisor needs to be aware of your attention to detail (and your co-workers lack of it.) We are all human and will make some errors along the way, but how will we learn if they are not pointed out? If your supervisor doesn't want to review so many discrepencies, then he/she should expect more from the coders the first time around. Good Luck!

  5. #5

    Default Risk Adjustment

    I am a supervisor or Risk Adjustment and nurse and a ceritifed coder. The reason why your are still able to submit the data to CMS is because as long as the HCC is valid, the data is correct. CMS_HCC model is a payment model that includes codes. One HCC can represent numerous codes. CMS is not asking you to validate the code you submitted, they are asking to validate the HCC. For example, if you submitted 250.00 or 250.02, it is the same HCC. Although the coding is not correct from a quality perspective, the HCC is still valid. This would require some education to the coder, but would not require deleting the data. Some coders ave a hard time changing gears when it comes to HCC's. The easiest way to clarifiy it is it is not a coding model it is a payment model. I hope this helps.

  6. #6
    Join Date
    Apr 2007
    Professional Coders of Central Pennsylvania (PCOCPA), Harrisburg, Pennsylvania


    It's my opinion that all diagnosis-code digits should be accurate, whether or not the HCC is the element being validated. From a health plan's perspective, HCC validation is very important, but from a general perspective, if diagnosis codes are assigned only partially correctly, CMS cannot accurately determine if additional diagnosis codes should be added to future eligible diagnosis code models. We must always be assigning the most accurate diagnosis codes, to their highest levels of specificity.
    Jennifer (Jenny) M. Oravecz, CPC
    Past Vice President/Education Officer (2012/2011) of Professional Coders of Central Pennsylvania (PCOCPA), Harrisburg, Pennsylvania
    Past President/President-Elect (2009/2008) of Professional Coders of Tidewater, Chesapeake, Virginia

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