Presentation on How to Encounter CMS & HHS RADV Audits [CEU]

Presentation of the
Risk Adjustment and
RADV Audits webinar
Holly Cassano
CPC, CRC, ICD 10CM Certified – One of
The Creators of the RA CRC AAPC Credential
and The AAPC National RA Exam
Kim Dues
CPC, CRC, ICD 10CM Certified
Hosted by
Held on: July 26th, 2017 | 1:30 PM EST

www.billingparadise.com | Copyright © 2017 BillingParadise
This is the PowerPoint version of BillingParadise’s recently
concluded webinar on Risk Adjustment and RADV Audits
A sneak peak of what’s in the presentation:
 Information on CMS’s Hierarchical Condition Categories
 HCC payment methodologies
 Documentation best practices
 Top 10 RADV red flags
 RADV medical record checklist
 Practice reminders
 Top 10 documentation issues

All-you-need-to know information on Risk
Adjustment and RADV Audits
3
• This presentation contains information on RADV Audits, which pertain to Risk Adjustment and how Providers and Coding Professionals,
must understand, that they too, can be on the hook in the event a Medicare Advantage Plan is audited and found to have deficiencies.
• CMS performs Risk Adjustment Data Validation (RADV) audits by reviewing provider medical record documentation to validate submitted
diagnoses codes, as they correlate to HCC codes. Risk Adjustment Factor Scoring or (RAF), when properly reported, allows CMS to
provide additional reimbursement to Medicare Advantage Plans, based on a Members’ overall health. The RAF scores are derived from
the submitted diagnoses from what should be in the medical record. Higher weighted RAFs, correlate to sicker patients, which means a
higher cost to the MA Plan to treat these sicker patients, hence, requires higher reimbursement to the MA Plans.
• The main avenue in which Risk Adjustment Fraud and Abuse occurs, is by reporting chronic conditions and subsequent treatment, on
patients that did not have the reported conditions or care, or upcoding on existing conditions, to make it seem more severe in nature than it
is.

What is CMS’s Hierarchical Condition Categories?
4
• Medicare Risk Adjustment payment model introduced by the Centers for Medicare and Medicaid (CMS) in 2004.
• The goal is to pay Medicare Advantage (MA) and Prescription Drug Plans (PDPs) accurately and fairly by adjusting
payment for Enrollees based on their demographics and their health status.
• This Risk Adjustment payment model measures the disease burden that includes 70 HCC categories, which are correlated
to diagnosis codes.
• Accurate diagnosis code documentation (ICD-10 CM) and reporting now determines reimbursement.
• 8,700 ICD-10 codes map to 1 of 70 HCCs (mostly chronic but some are acute). Previously in ICD-9 it was 3,600 codes.

The Process
5
Care is Delivered to the
Member (face-to-face
encounter)
Care and Diagnoses are
Documented in the Chart /
Progress Notes
Claims data diagnosis codes
are converted to HCC codes
ICD-10 CM codes are submitted on
Claims based on the face-to-face
encounter clinical findings
HCC codes data is submitted
to CMS
CMS Calculates MA Risk
Adjustment
Plan & Providers can Deliver
better care
And reimbursement is
received

Payment Methodology
Payments are based upon acuity of diagnosis.
• Sicker patients will require more health care resources.
• Diagnoses must be reestablished each year to ensure that
next year’s payments will cover costs.
For example, an amputation must be reported at least once per year to ensure that services related to this condition will be covered.
• Documentation must support the diagnoses that are reported
AND A PLAN FOR EACH DIAGNOSIS.
Often times physicians get familiar with patients over time and neglect documentation of chronic stable conditions.
6

PAYMENT RUN DATES 2016-2017 – INCL INITIAL 2018 DATE
DATE: April 20, 2016
TO: All Medicare Advantage Organizations, PACE Organizations, Medicare-Medicaid Plans, Section 1833 Cost Contractors and Section 1876 Cost Contractors, and
Demonstrations
FROM: Cheri Rice, Director Medicare Plan Payment Group
SUBJECT: Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2016, 2017, and 2018
This memo is to notify Medicare Advantage Organizations, PACE Organizations, Medicare-Medicaid Plans, Section 1833 Cost Contractors and Section 1876 Cost
Contractors, and Demonstrations of upcoming deadlines to submit risk adjustment data for use in calculating risk scores for Payment Years (PY) 2016, 2017, and 2018.
All risk adjustment data (Risk Adjustment Processing System Data and Encounter Data System Data) that will be included in the listed risk score runs need to be
submitted by the "Deadline for Submission."
For Payment Year 2016, the blended risk score -- 10% of the risk score calculated with diagnoses from encounter data and FFS summed with 90% of the risk score
calculated with diagnoses from RAPS and FFS -- will be implemented when we calculate the final PY 2016 risk scores.
Risk Score Run Dates of Service Deadline for Submission of Risk Adjustment
Data
2017 Initial (RAPS) 07/01/2015 — 06/30/2016 Friday, 09/09/2016 2016
Final Run (RAPS and EDS) 01/01/2015 — 12/31/2015 Tuesday, 01/31/2017 2017
Mid-Year (RAPS and EDS) 01/01/2016 — 12/31/2016 Friday, 03/03/2017 2018
Initial (RAPS and EDS) 07/01/2016 — 06/30/2016 Friday, 09/08/2017

 For Payment Year 2017, the blended risk score -- 25% of the risk score calculated with diagnoses from encounter
data and FFS summed with 75% of the risk score calculated with diagnoses from RAPS and FFS -- will be
implemented when we calculate the mid-year PY 2017 risk scores.
 Questions related to this guidance should be sent to riskadiustment@cms.hhs.gov. Please use `1-1PMS Memo-
Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2016,
2017, and 2018' as the subject in all communications regarding this guidance.
PAYMENT RUN DATES 2016-2017 – INCL INITIAL 2018 DATE (contd.)

HCC Payment Methodology
and ICD-10 Coding
Physicians will need to be more specific in their documentation than they may have been in the past. There is a greater number of codes in ICD-10
versus ICD-9.
• Physicians will need to pay more attention to their medical documentation, to make sure that it contains the necessary details so that staff
members can choose the right codes for each patient.
• Besides the increased specificity of a diagnostic code, doctors also face other documentation challenges, including identification of:
 Conditions that contributes to the complexity of a disease
 The severity of a contributing comorbidity
 The current stage of a disease (such as chronic kidney disease, dementia, or asthma)
 The type of diabetes and its severity
 A complete history of any present illnesses and follow-up visits
9

Coding Changes with ICD-10
Diabetes documentation must include:
 Type of diabetes
 Body system affected
 Complication or manifestation
 If a patient with type 2 diabetes is using insulin, a
secondary code for long term insulin use is required
10
Neoplasms documentation must include:
 Type:
Malignant (Primary, Secondary, Ca in situ)
Benign
Uncertain
Unspecified behavior
 Location(s) (site specific)
 If malignant, any secondary sites should also be
determined
 Laterality, in some cases
Asthma documentation must include:
 Severity of disease:
 Mild intermittent
 Mild persistent
 Moderate persistent

Coding Changes with ICD-10 Diabetes
 There are over 200 ICD-10 codes for diabetes. Medical record documentation must be more
specific regarding the disease in order to choose the most appropriate code. Providers MUST
create a link between diabetes and its complications.
 There are also some new categories of DM complications in ICD-10: DM with skin
complications, DM with oral complications, and DM with arthropathy.
 Providers will be required to draw a causal link between the type of diabetes and the
complications. Under ICD-10, more than ever, clear and concise documentation will be critical to
ensure correct coding and to receive appropriate reimbursement for your risk population.
11
Coding Changes

Examples of Diabetes in ICD-10
KIDNEY DISEASE
E10.22
Type 1 Diabetes with kidney complications E11.22 Type 2 Diabetes with kidney complications
( Use additional codes listed below to identify complication) ( Use additional codes listed below to identify complication)
I12.9
Nephropathy w/HTN and CKD (Stages I-IV)
I12.9
Nephropathy w/HTN and CKD (Stages I-IV)
I12.0
Nephropathy w/HTN and CKD (Stages V-VI)
I12.0
Nephropathy w/HTN and CKD (Stages V-VI)
N08
Glomerular disorders in diseases classified elsewhere
N08
Glomerular disorders in diseases classified elsewhere
N04.9
Nephrotic syndrome with unspecified morphologic changes
N04.9
Nephrotic syndrome with unspecified morphologic changes
N03.8
Chronic nephritic syndrome with other morphologic changes N03.8
Chronic nephritic syndrome with other morphologic changes
N18.1
Chronic kidney disease (CKD), stage I
N18.1
Chronic kidney disease (CKD), stage I
N18.2
CKD, stage II (mild)
N18.2
CKD, stage II (mild)
N18.3
CKD, stage III (moderate)
N18.3
CKD, stage III (moderate)
N18.4
CKD, stage IV(severe)
N18.4
CKD, stage IV(severe)
N18.5
CKD, stage V
N18.5
CKD, stage V
N18.5
End stage kidney disease (ESRD)
N18.5
End stage kidney disease (ESRD)
N18.0
Chronic kidney disease, unspecified
N18.0
Chronic kidney disease, unspecified
Z99.2
Dependence on renal dialysis
Z79.4
Insulin use
Z99.2
Dependence on renal dialysis
12

Chart Documentation
Each patient encounter should include:
 Reason for the encounter with relevant history
 Examination findings
 Diagnostic test results
 Assessments
 Clinical impressions
 Plan of care
13

Document, Document, Document
Goal = Properly Reflect the Member’s Health Status
• Fully assess ALL Chronic Conditions ….…at least annually
• Thoroughly Document in the Chart (Progress Notes) ALL conditions evaluated for each
visit
• Code to the Highest Level of Specificity (fully utilize the ICD-10 Diagnosis Coding
System)
14
Is your
documentation
sufficient to fund
the care for your
sicker patients?

HCC Coding Impact to Revenue
CMS Revenue paid to Health
Plan
o All conditions coded
appropriately: $2,624
o No conditions coded: $528
All conditions coded appropriately – High level
High level of specificity
Some conditions coded – Moderate level of
specificity
Minimal conditions coded – Low level of specificity
76 year old female 0.437 76 year old female 0.437 76 year old female 0.437
Medicaid eligible
(aged female 65+)
0.151 Medicaid eligible
(aged female 65+)
0.151 Medicaid eligible
(aged female 65+)
0.151
Diabetes w/ vascular complications
complications
E11.59 (HCC 18)
0.368 Diabetes w/ vascular complications
complications
E11.9 (HCC 19)
0.118 No diabetes coded X
Vascular disease w/ complications 1.413 Vascular disease w/o complications 0.299 No vascular disease coded X
CHF I50.9 (HCC 85) 0.368 CHF not coded X CHF not coded X
Disease Interaction
(DM + CHF)
0.182 No Disease Interaction X No Disease Interaction X
Total RAF 2.919 Total RAF 1.005 Total RAF 0.588
15

Treating, Managing or Assessing the Chronic Conditions
In order for CMS to make the payment to the health plan the diagnoses submitted must be from a face-to-face visit and the visit must
indicate how the chronic conditions are being Monitored, Evaluated, Assessed and Treated: = M.E.A.T.
Sample language:
Example: Hypertensive CKD III, stable well controlled, continue meds
Example: COPD, stable on Advair
Reference: CMS-Centers for Medicare & Medicaid Services, "2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations
Participant Guide." Leading Through Change, Inc. 2008 1-49. 1 Centers for Medicare & Medicaid Services, (1995). 1995 documentation guidelines for
evaluation & management
Assessment Plan
Stable Monitor
Improved D/C meds
Tolerating meds Continue meds
Deteriorating Refer

Annual Wellness Visit
Medicare Annual Wellness Visit Requirements
• Medication Review
• Allergies or NKDA listed
• Vital Signs (Include BMI)
• Physical Examination/ Assessment and Treatment Plan for Members
Medical Conditions
• Referrals needed for Preventive Health Review (Colon Cancer, Labs,
and Bone Density)
• Discussion regarding Advance Directive or End of Life documented in
the progress note
Preventive Health Review
• Preventive Health Counseling on the
following
• Improving and Maintaining Physical
Activity
• Bladder control issues
• Fall risks and fall prevention
• Improving and maintaining physical
health
• Improving and maintaining mental health
• Pain scale (0-10)
• Functional Assessment that addresses
• Continence
• Mobility/Transferring
• Feeding
17
CPT code
Coding Requirements
Initial Assessment G0438 Established
Assessment G0439
• Bathing
• Dressing
• Toilet Use
• PsychologicalAssessment (PHQ-9)
• Diabetic Patients
• Hba1c Test
• Diabetic Retinal Exam
• Attention Nephropathy
• Diabetic Foot Exam
• Rheumatoid Arthritis patients Medication
Management (Age 18+)
• Osteoporosis Management (women 65+)
Bone Density test, medication
• Influenza vaccine
• Cognitive Assessment (6CIT)
• Colon Cancer Screening
• Breast Cancer Screening

Annual Wellness Visit Forms
18

Audits – In General
CMS audits medical records to validate documentation.
Validation Audits
• Superbills are not considered sufficient documentation… they are a reporting
format only.
• Documentation must show the diagnosis was assigned within the data collection
period.
• Data discrepancies that are found as a result of audit may cause a risk adjusted
payment to be changed.
19

CMS RADV AUDITS – What???
 RADV is a method of evaluating/validating the accuracy of the diagnoses submitted for payment.
 RADV – Risk Adjustment Data Validation Audit
 RADV is a corrective action to help reduce the Part C error rate.
 Each year, CMS reports a National Payment Error Estimate to comply with the Improper Payments Elimination and
Recovery Act (IPERA) of 2010*
 http://www.cms.gov/Medicare/Medicare-Advantage/Plan-Payment/PaymentValidation.html
 CMS expects that RADV will have a sentinel effect on quality of risk adjustment data submitted for payment going
forward into the Healthcare Continuum of Value Based Payments and overall management of Chronic Care.
20

RADV AUDITS – Cont’d
 A CMS audit that ensures the integrity and accuracy of risk-adjusted payment
 Verifying that the diagnosis codes submitted by the Medicare Advantage plans are supported by the medical record
documentation for a member
 MA plans can be selected for RADV Audits annually; If selected, MA plans are required to submit member medical records to
validate diagnosis data previously reported to CMS
 Providers should be aware of RADV Audits because providers are required to assist the MA plan by providing medical record
documentation for members included in the audit
 Section 1853(a)(3) of the Social Security Act requires that CMS risk adjust payments to Medicare Advantage (MA) organizations.
In general, the current risk adjustment methodology relies on enrollee diagnoses, to prospectively adjust capitation payments for
a given enrollee based on the health status of the enrollee.
21

RED FLAGS
Members with 7 or more HCCs
Members with + 1 in RAF score from prior year
Top 1/3 paid stratum (Diagnosis/HCC/RxHCC)
High distribution HCCs
Active vs. History of
22
Vascular disease
Diabetes with complications
Major depression
Protein Calorie Malnutrition
More than 1 Status Codes per Member
Top 10 RADV Red Flags

MAO-SUBMITTED RISK ADJUSTMENT
DIAGNOSES MUST BE:
 Based on clinical medical record documentation from a face-to-face encounter
(patient and provider)
 Coded in accordance with the ICD-10-CM Guidelines for Coding and Reporting
 Assigned based on dates of service within the data collection period
 Submitted to the MA contracts by acceptable: RA provider type / RA provider data
source
23

RADV PROCESS
24
CMS requests records that are selected based on enrollment data for January of the payment year
Eligible enrollees:
 12 months of Part B during data collection year (i.e., Full Risk) - Continuously enrolled in the same
contract from January of the data collection year through January of the payment year
 Non-ESRD in status from January of the data collection year through January of the payment year;
 No hospice-only status from January of the data collection year through January of the payment year;
 At least one CMS-HCC assigned All CMS-HCCs for selected enrollees will be reviewed

RADV PROCESS Con’t
25
Medical Record Review
 Records submitted for RADV first undergo an intake evaluation
 For outpatient and physician records, a CMS-Generated
Attestation may be submitted with a record that is missing a
provider’s signature and/or credential
 Only valid records go forward for coding

Medicare Advantage Plans have to submit the "One Best Medical Record" that supports
each HCC identified for validation.
26
*****Effective with the CY 2011 RADV audits, CMS will allow audited MA contracts to
submit up to five medical records for each audited CMS-HCC per enrollee.
What does this mean? The MA plan can choose to submit one of the
following:
 A hospital inpatient
 Hospital outpatient
 Or physician medical record when more than one option is available

RISK ADJUSTMENT DATA VALIDATION (RADV) MEDICAL RECORD
CHECKLIST AND GUIDANCE
27
 CMS created the Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance
 To assist contracts in selecting appropriate medical records
 The guidance is based on issues CMS observed with medical records submitted for previous RADV audits
 The guidance addresses issues observed during intake (incorrect date of service, unacceptable provider
type, etc) and coding (diagnosis cannot be verified using ICD-10 guidelines).
 http://www.cms.gov/Medicare/Medicare-Advantage/Plan-Payment/Downloads/radvchecklist.pdf

RADV FINDINGS
 At the conclusion of the initial medical record review process, results will be issued to audited contracts in the form of
the Preliminary Audit Report of Findings (AROF)
 For each audited CMS- HCC the Preliminary AROF will detail the validation outcome, error type (if applicable), and
eligibility for medical record dispute
 For each enrollee, the preliminary AROF will detail calculation of the corrected risk score and payment, based on initial
medical record review results
 Contracts will receive information and instructions on medical record dispute (MRD) with the preliminary AROF
28

PRACTICE REMINDERS:
Diagnosis codes submitted by MA organizations are used to determine beneficiary risk scores, which in turn determine the risk adjusted
reimbursement.
The major areas of concern are pointed out to plans to communicate to networked providers, in order to reduce/eliminate fraud, abuse and
waste within the system:
 Documentation must support the code selected and substantiate that the proper coding guidelines were followed.
 Data validation ensures that both are appropriate.
 Upcoding or changing diagnoses to obtain higher reimbursement without supporting source documents is fraudulent.
 The risk adjustment diagnosis must be based on clinical medical record documentation from a face to face encounter.
 Must be coded according to the ICD 10CM Guidelines for Coding and Reporting;
 Assigned based on dates of service within the data collection period,
 Submitted to the MA organization from an appropriate risk adjustment provider type and an appropriate risk adjustment physician data source."
29

Top 10 issues with documentation
Top 10 fails in documentation:
1. Failing to capture HCCs at least once every 12 months.
2. Failure to ensure the medical record contains a legible signature with
credential.
For example, determine whether such as the electronic health record was unauthenticated
(not electronically signed).
3. Failure to ensure the diagnosis codes being billed and the actual medical
record documentation match.
4. Failure to document according to the M.E.A.T. principles. Diagnoses need to
be monitored, evaluated, assessed/addressed, and treated.
5. Failing to annually document status Z codes and chronic conditions.
30
6. Failing to use a linking statement or document a causal relationship for
manifestation codes.
7. Failing to add any diagnosed HCCs or RxHCCs (prescription drug HCCs)
to both the chronic problem list and the acute assessment.
8. Failing to evaluate each of the HCCs/RxHCCs on a semiannual basis for
updates.
9. Failing to review all specialist documentation related to cardiology, master
discharge summaries, radiology, specialty correspondence, pulmonary,
echocardiograms, and x-rays, laboratory results, and previous encounters.
10.Failing to submit more than the standard four ICD-10-CM codes.

THANK YOU!!
31
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