How to Successfully Manage and Survive a CMS/HHS-RADV Audit

How to successfully manage and survive a CMS/HHS-RADV audit

PALM SPRINGS, Calif—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 encounters and claims against the data provided to CMS per the RADV audit.

Her advice based on past audits: Establish your internal team early. Although some organizations may turn to external vendors, Curry said she prefers to use internal staff who can help by conducting retrospective coding. They can also gain experience by auditing a chart the way an auditor would. Once the coder reviews the chart, Curry serves as the secondlevel review. She also suggests remaining flexible because the CMS audit dates are often subject to change.

The most common coding errors she has seen include acute (critical) condition codes in an office setting, such as acute stroke or heart attack (Place of Service Code 11); infrequently coded conditions, such as cancer, chronic condition not captured year over year; and suspect or rule-out conditions in an outpatient setting (per coding guidelines these are only acceptable during an inpatient stay). If doctors have ruled out a condition before the definite diagnosis, it is not valid and the coder shouldn’t have captured it, she explained.

Best practices to keep in mind for a future audit include implementing a quarterly internal quality audit process. That means you should establish an audit team now, Curry said. If you are unsure who to put on the team, Curry said to consider who you would call if you needed to recover documents after a disaster. She suggests the audit team include representatives from compliance, finance, enrollment or member services, risk adjustment (coders, analysts), 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.