CMS issued medical coder guidance for risk adjustment data validation last month.
Here are three things to know.
1. CMS uses risk adjustment to reimburse Medicare Advantage Organizations based on enrollees' health status and demographic characteristics, according to a Lexology report. MAOs are required to submit risk adjustment data and certify submissions are accurate, complete and truthful.
2. CMS conducts risk adjustment data validation audits to ensure diagnosis codes in the submissions are correct and documented in medical records. "Historically, MAOs have been frustrated by the lack of clear guidance from CMS on the requirements for risk adjustment data submissions," Lexology notes.
3. Beginning Sept. 27, CMS started using the guidance for its auditing. The guidance outlines clearer expectations regarding medical record coding for the MAOs. Lexology projects this will allow MAOs "to implement more effective compliance and vendor oversight activities. Given the number of risk adjustment related federal civil False Claims Act cases that are pending, review of the Medical Record Reviewer Guidance by MAOs is strongly recommended."
For the full coding guidance, click here.
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