Did you know that every January, Medicare and Medicaid clear the risk adjustment slate for your patients? That means, they consider your patients completely healthy until new diagnosis codes are reported on claims. For that reason, providers must document the persistent conditions of patients, such as diabetes, chronic kidney disease, congestive heart failure, COPD, malignant neoplasms and more, every year.
CMS’ purpose is to risk adjust costly, chronic diseases that will appropriately assess how sick your patients are – and will help them determine future reimbursement rates. The CMS risk adjustment model measures the disease burden that includes 70 Hierarchical Condition Categories (HCC), correlated to diagnosis codes. To support the HCC, clinical documentation in the patient’s health record must support the presence of the condition and indicate the provider’s assessment and/or plan for management of the condition.
A great opportunity to document PCVs is during your patients’ Annual Wellness Exam. In the AEHR, on the claim, note the Annual Wellness Exam as the primary purpose of visit. Then subsequently list all PCVs. You can also document PCVs during sick visits, again by listing the current illness as the primary visit purpose, then listing PCVs.
The under-coding of PCVs can lead to underpayment of claims and loss of revenue, while over-coding can lead to audit risk and compliance actions. See the example that follows:
CMS does conduct random risk adjustment data validation audits to verify the accuracy of diagnosis codes submitted, to ensure the medical record supports the diagnosis and code, that the provider signature is valid, and to review provider credentials. The importance of consistent, accurate, and complete documentation in the medical record can’t be overemphasized!
Currently, persistent condition validation (PCV) must be done for all Medicare, Medicare Advantage, and Medicaid patients.