New White Paper | The Health of Your Health Plan: Removing Data Silos, Improving Efficiency, and Moving Toward Interoperability in Healthcare

Advance Possibility

7 Key Conditions That Can Cause Diagnosis Codes to Fail a Risk Adjustment Audit

July 4, 2024

The Centers for Medicare & Medicaid Services (CMS) carry out risk adjustment data validation (RADV), a risk adjustment audit on health plans, to maintain the precision and integrity of the risk adjustment data provided for Medicare Advantage (MA) risk adjustment payments. RADV involves confirming that the diagnosis codes submitted for payment by an MA organization are backed by medical record documentation.

In the complex landscape of healthcare, accurate risk adjustment is paramount for ensuring fair compensation and appropriate care delivery. Amidst this intricate process, identifying the key determinants that would increase likelihood to not pass a risk adjustment audit becomes essential. Let’s delve into the key criteria that would increase likelihood to not pass a risk adjustment audit as highlighted by the CMS RADV Medical Record Checklist and Guidance.

1. Inpatient Hospitalization Records: For conditions warranting inpatient hospitalization such as septicemia, cerebral hemorrhage, cardiorespiratory failure, and shock, you must be sure to submit corresponding inpatient records. These may include stand-alone inpatient consultation records or discharge summaries, providing comprehensive documentation to support Hierarchical Condition Categories (HCCs).

2. Specialist Records: When feasible, obtaining records from specialists treating specific conditions, like oncologists for cancer diagnoses, is recommended. Such records are often more detailed and can better document the condition, reducing risk to get targeted for a  risk adjustment audit.

3. Attention to Cancer Diagnoses: Cancer diagnoses require meticulous documentation. Merely indicating a “history of cancer” without current treatment details may not suffice for validation. Ensure records reflect current treatment status within the data collection year to validate cancer-related HCCs effectively.

4. Electronic Medical Record Problem Lists: Thoroughly review problem lists in electronic medical records. While certain diagnoses may persist on the list even after resolution, others may not accurately capture HCCs submitted for payment. Ensure that problem lists align with submitted HCCs and include comprehensive documentation. Furthermore, any problem list within the submitted documentation should be directly included rather than merely referenced.

5. Manifestations or Complications Documentation: Records validating HCCs encompassing additional manifestations or complications should establish a clear causal link between the disease and the complication. Physicians specializing in the respective field should explicitly define and link the relationship, ensuring accurate validation of the HCC.

6. Provider Signatures and Credentials: Missing provider signatures and credentials in physician or outpatient records can pose validation challenges. Utilizing CMS-Generated Attestations provided with the data becomes essential in such cases, as CMS considers these attestations for RADV purposes.

7. Minimum Requirements for Inpatient Records: Inpatient records must meet minimum requirements, including admission and discharge dates. Additionally, stand-alone consultations should include the consultation date, while stand-alone discharge summaries from physician providers must contain the discharge date for comprehensive documentation.

By paying meticulous attention to these key risk adjustment audit triggers, healthcare organizations can ensure accurate and thorough documentation. Adhering to CMS guidelines and leveraging comprehensive medical records can help avoid triggering an audit. If an audit does occur, following these tips will position your organization to respond effectively, ultimately enhancing quality care delivery and financial stability.

Episource offers comprehensive solutions to assist clients in managing both retrospective and prospective coding challenges. Episource’s Retrospective Review simplifies the review of historical codes to ensure they align with the key 7 conditions that can cause diagnosis codes to fail an RADV audit and comply with the OIG’s recently published toolkit. Additionally, Episource’s Final Check Review helps mitigate risk adjustment audit triggers for current and future coding projects. Final Check Review leverages our industry-leading NLP coding engine to automatically detect codes that were missed during other vendors’ prior audits. Each suspected code is manually validated against CMS and client guidelines by our large team of in-house coding experts. In this process, provide incremental RAF for previously missed HCC codes. Access our case study to learn how a Medicare Advantage Plan identified unrealized reimbursement with a NLP-powered second-level review despite having 98% coding accuracy prior to the review. 


Risk adjustment data validation (RADV) medical record … CMS. (n.d.).