There has been a significant and sustained increase in medical record requests from Medicare Advantage insurers for risk adjustment, aimed at finding additional diagnoses to reflect higher patient "sickness" scores and maximize payments. This practice, often labeled as "chart review" or "chart harvesting," has led to accusations of artificially inflating risk scores and, consequently, Medicare payments. Ultimately, this is not a provider issue, rather the Med advantage plans working to receive higher pay outs from CMS for the more chronic and sick conditions based on the prior implementation of risk adjustment that they benefit from.
HCC Risk adjustment is a statistical method used by the Centers for Medicare & Medicaid Services to adjust capitated payments to Medicare Advantage (MA) plans based on the health status and demographic factors (age, sex) of enrollees. “CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS”, whereby making monthly payments based in part on the health status of the enrollees being covered. It was designed to predict future healthcare costs, paying more for sicker patients to encourage care access, and was created as a way to help make sure doctors and other health providers are paid fairly for the people they treat by using the CMS-Hierarchical Condition Category (CMS-HCC) model to assign a risk score.
This risk adjustment model was never intended to be used in a way that inflates Medicare payments to advantage plans. Oversight organizations, such as the OIG, are aware of payer noncompliance, as evidenced by reports published across multiple insurance carriers. One such report estimates that Priority Health received at least $4.4 million in net overpayments for 2018 and 2019 due to noncompliance with federal requirements. “For 252 of the 300 sampled enrollee-years, medical records did not support the diagnosis codes and resulted in $828,010 in net overpayments.” This offers little comfort to providers managing Medicare Advantage plans, particularly given the significant staff time required to respond to record requests.
The IMA has received inquiries from clinics with Med Adv plans wanting different diagnosis codes than what seems appropriate. For example, one clinic received commonly missed HCC codes under “Medications for any patient on chronic: F11.XXX -Opioid use, dependence, or abuse; F13.20 - Anxiolytics, or sedatives (sleep meds); and F15.20 - Stimulants (ADHD).” For a patient on long term (current) opioid management, the proper diagnosis is reported with Z79.891 as a medical treatment by a medical provider and not reported as F11.XXX Opioid use, dependence, or abuse as a behavioral and mental health disorder. Per ICD10 guidelines, “Assign a code from Z79- if the patient is receiving a medication for an extended period as a prophylactic measure or as treatment of a chronic condition or a disease requiring a lengthy course of treatment.” Codes in category Z79- are not used “for patients who have addictions to drugs”. Similarly, patients on other long term medication management they listed would not be reported as sedative dependent or stimulate dependent as these are mental and behavioral health disorders.
We would advise clinics to base their coding on the ICD10 guidelines and not to inflate them or miss-report based on pressures from Med advantage plans. Some of this pressure not only up-codes diagnoses, but it also labels patients with conditions that were not diagnosed by a provider and do not follow the appropriate ICD10 guidelines for reporting. We urge providers to follow all CMS, AMA, and ICD10 guidelines. Here are some basic ICD10 rules for appropriate diagnosis coding When in doubt, please reach out to the IMA for guidance.
Diagnoses code selection:
• Should be based on diagnoses managed and documented
• Should be coded to the highest specificity
• Should not be pulled from an active problem list, unless it is being addressed with history, exam, A/P, or indicated in the decision making
• Should include all documented conditions that coexist at the time of the encounter and require or affect management; should not include conditions previously treated that no longer exist
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