Audit Provider Documentation to Ensure Accurate Risk Adjustment

Norwood performs CMS compliance-level audits for its partner organizations. These audits involve:

  • Evaluation of provider documentation
  • Review of billed codes
  • Determining whether codes are supported in the documentation
  • Evaluating code accuracy
  • Determining whether a higher (or lower) degree of specificity is warranted

Following these steps, we compile the results into a detailed summary of the findings. Once complete, the next step is to educate and give feedback to the CDI team, HIM/coding, auditors, and providers to improve their processes for documentation capture and accurate code assignment.

Our process has revealed patterns of both over-coding and under-coding. Let’s take a deeper dive into the root causes of each.

Over-coding example: Acute strokes in the outpatient setting

In this example, a patient follows up with his neurologist three months after suffering a stroke that required an inpatient admission and treatment. At the follow-up visit, they are evaluated for hemiplegia, a sequela from the stroke. The provider documents “acute stroke” in the assessment, orders PT/OT for the patient, and signs off on the visit note. An E/M service is now being billed with an inappropriate diagnosis code of I63.9 (Cerebral infarction, unspecified).

This claim is likely to be denied. It also creates risk for the organization from a risk adjustment perspective. Why?

The acute stroke is no longer active at the outpatient office visit; instead, the patient is following up after the acute stroke is over and they have been discharged from the inpatient setting. The documentation should have instead supported the condition that actively exists—the hemiplegia. The proper code assignment falls in the I69.- series (sequelae of cerebrovascular disease). If no sequelae were present, the correct code assignment would be Z86.73, Personal history of TIA and cerebral infarction, without residual deficits.

In addition to erroneous stroke coding, our audits have also revealed consistent errors in reporting acute myocardial infarctions (outside the four-week window allowable per guidelines), acute pulmonary embolisms, and the treatment of DVTs, cancers, and neoplasms. Most of these findings mirror those discovered during recent Office of Inspector General (OIG) audits.

Under-coding example: History of diabetes

In this example, a provider sees a patient with diabetes that clinically requires ongoing management, but the provider documents “history of diabetes” without further support evident in the record that this condition still exists.

While the condition may be present and chronic from the clinical perspective, the coding professional sees the “history of” without further support in the note, inteprets the provider documentation to mean the condition no longer exists, and does not report diabetes. This impacts the patient’s risk score and, ultimately, organizational reimbursement.

How do these errors occur? It’s subtle but pervasive.

Many providers use the terminology “history of” to denote that a patient is dealing with, or has dealt with, a condition over time. The provider chooses accurate clinical terminology to represent an ongoing, long-term history of the condition, but that documentation means something different in coding language. A solution for this can be as simple as “the patient has diabetes” and providing documentation support for the management of the condition.

Other culprits include a shift of code assignment duties placed on providers, who are not necessarily trained in coding concepts. The assignment of codes from drop-down menus without enough knowledge of Official Guidelines for Coding and Reporting also impacts accuracy. Increasingly, artificial intelligence scans the record and auto-codes diagnoses in error, failing to contextualize the code in the broader picture. For example, picking up “diabetes” from a review of systems that actually says “no history of diabetes.”

Preventing over- and under-coding requires a thorough review of documentation, determining the presence of active treatment and support for the condition or whether it should be reported as historical, and issuing a query from the CDI or coding team to the provider if the documentation is unclear.

We’re your risk adjustment solution

Is your organization in need of a risk adjustment audit? Consider Norwood. Learn more about our full set of Solutions or contact us here.

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