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How to successfully manage and survive a CMS/HHS-RADV audit
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t is possible to survive a Medicare Advantage Risk Adjustment Data Validation Audit, according to Deb Curry, RHIA, CCS-P, manager, risk adjustment, of Promedica, who spoke at RISE WEST 2018.
Deb Curry, RHIA, CCS-P, manager, risk adjustment, Paramount Healthcare, an affiliate of Promedica, and a self-described “coding geek,” conducted a session at RISE West 2018 on lessons learned from past audits and best practices to minimize errors. Rest assured, she told participants, you will survive a Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) Audit. CMS conducts the audits to ensure the integrity and accuracy of the providers data submission to substantiate risk adjustment. The agency’s goal is to identify any discrepancy by comparing risk adjustment diagnosis data submitted by Medicare Advantage organizations via coded conditions, such as cancer, chronic encounters and claims against the data provided condition not captured year over year; and to CMS per the RADV audit. suspect or rule-out conditions in an outpatient setting (per coding guidelines these are only Her advice based on past audits: Establish acceptable during an inpatient stay). If doctors your internal team early. Although some have ruled out a condition before the definite organizations may turn to external vendors, diagnosis, it is not valid and the coder shouldn’t Curry said she prefers to use internal staff who have captured it, she explained. can help by conducting retrospective coding. They can also gain experience by auditing a Best practices to keep in mind for a future chart the way an auditor would. Once the coder audit include implementing a quarterly internal reviews the chart, Curry serves as the secondquality audit process. That means you should level review. She also suggests remaining establish an audit team now, Curry said. If you flexible because the CMS audit dates are often are unsure who to put on the team, Curry said subject to change. to consider who you would call if you needed to recover documents after a disaster. She The most common coding errors she has seen suggests the audit team include representatives include acute (critical) condition codes in an from compliance, finance, enrollment or member office setting, such as acute stroke or heart services, risk adjustment (coders, analysts), attack (Place of Service Code 11); infrequently actuarial, and a project lead/internal auditor.
But most importantly, she said, engage the provider community. Plans must work with them to make sure they code to the highest specificity and ensure documentation is accurate. Acceptable documentation must be clear, concise, consistent, complete, legible and signed. If signed electronically, it must include their first and last names and credentials. Otherwise, it won’t be acceptable. For more information on risk adjustment, consider attending the 12th Risk Adjustment Forum and/or RISE Nashvillle.
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