Increased Enforcement for Risk Adjustment Coding

Risk adjustment coding has the been source of several recent large, false claims act settlements and is also the topic of a recent OIG Work Plan Audit Report.  The most recent  false claims settlement, cost one health system $90 million.  

In virtually all cases, the allegations and identified errors resulted from reporting of diagnoses not supported by the medical record.

The OIG’s audit focused on “high risk” diagnosis categories including: Acute stroke Acute heart attack Embolism Major depressive disorder Vascular claudication The specific types of coding errors noted included: Reporting of past medical conditions as current Reporting of conditions not documented as definitive diagnoses (i.e. possible, probable, suspected) Reporting of conditions which were documented as definitively ruled-out  Reporting of conditions not documented in the medical record Reporting of current conditions for which the documentation did not reflect any active treatment or care impact Reporting of conditions as “severe” when the documentation specified the condition as “mild” If your organization participates with risk adjustment coding and reimbursement, we recommend you conduct auditing of these known high risk areas and evaluate your internal controls to support compliance.  Careful attention should be given to those diagnosis categories identified by the OIG as high risk.

The OIG Audit report may be located here:

The most recent DOJ settlement may be located here:

HBE’s team of coding and compliance experts is available to assist you with external reviews of your documentation, coding and reimbursement.  Additionally, we can provide customized documentation and coding education and training for your clinical and coding staff.  We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.  
DISCLAIMER:  This newsletter only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel.

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