Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements. To conduct the audit, they reviewed one Medicare Advantage (MA) organization based in St. Louis.
They selected 218 unique enrollee-years with high-risk diagnosis codes during calendar years 2012 through 2014. The 218 enrollee-years included 52 diagnoses of acute stroke and 166 diagnoses of major depressive disorder. The review was limited to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $515,325.
For 75 of the 218 enrollee-years, the diagnosis codes (48 acute stroke and 27 major depressive disorder) submitted to CMS were either:
- Not supported in the medical records (70)
- Not supported because they could not locate the medical records (5)
These errors occurred because the policies and procedures they had in place to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. As a result, they received $158,904 of overpayments for the 75 enrollee-years.
According to the report, the OIG will continue auditing MA organizations because some diagnoses are at higher risk for being miscoded, like acute stroke and major depressive disorder.
So how can your facility or physician practice avoid a similar situation? The answer is two-fold: get quality coding support and/or have consistent audits performed throughout the year.