With the recent Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) Final rule update shared by the Centers for Medicare & Medicaid Services (CMS) to collect improper payments made to the MA organizations, value-based healthcare payers are now under tremendous pressure to ensure accurate medical record documentation for passing appropriate reimbursements.
Below is a list offered to MA organizations to determine the medical record’s suitability for RADV:
- Is the record for the correct enrollee?
- Is the record from the calendar year for the payment year (i.e., for audits of 2023 payments, validating records should be from
- Is the date of service present for the face to face visit?
- Is the record legible?
- Is the record from a valid provider type? ( Hospital inpatient, hospital outpatient/ physician)
- Are there valid credentials and/or is there a valid physician specialty documented on the record?
- Does the record contain a signature from an acceptable
- If the outpatient/ physician record does not contain a valid credential and/or signature, is there a completed CMs-Generated Attestation for this date of service?
- Is there a diagnosis on the record?
- Does the diagnosis support an HCC?
- Does the diagnosis support the requested HCC?
Source: CMS
Please note: For any of the items shared in the image above an answer ‘No’ may indicate that the medical record will not support a CMS-HCC.
What are the points to be considered before submitting a record for RADV audit?
As per CMS RADV Medical Record Checklist and Guidance:
- For a condition that warrants an inpatient hospitalization, the HCC may be supported by an inpatient record. An inpatient record, a stand-alone inpatient consultation record, or a stand-alone discharge summary is suggested for ensuring appropriate submission.
- A record from the specialist treating the condition is needed whenever possible. For e.g., an oncologist for a cancer diagnosis. Having such records will help sufficiently document the condition.
- A notation indicating ‘history of cancer,’ without an indication of current cancer treatment, may not be sufficient for validation. Therefore it is always recommended to pay special attention to cancer diagnoses to ensure HCC validation.
- It is also suggested to pay special attention to the problem list on electronic medical records. Depending on the systems, a diagnosis may never drop off the list, even if the patient is no longer suffering from the condition. Conversely, the problem list may skip documenting the HCC your MA contract submitted for payment.
- Furthermore, any problem list in submitted documentation should be included and not just referenced.
- Records submitted to validate HCCs that forecast additional manifestations or complications related to the disease (e.g. HCC 15, Diabetes with Renal Manifestations, or Diabetes with Peripheral Circulatory Manifestations) will have to include language from an acceptable physician specialist that establishes a causal link between the disease and the complication. For records that do not define and link this relationship may not validate the HCC.
- Consider using the CMS-Generated Attestation that was provided with your data in case a physician or outpatient record is missing a provider’s signature and/or credentials, CMS will only consider CMS-Generated Attestations for RADV.
Looking for an Advanced HCC chart review & audit to withstand RADV audits? Inquire now!
Click to read about MA RADV Final Rule.
