Solutions Spotlight: OIG Toolkit a Valuable Blueprint for Risk Adjustment Coding Compliance

By Brian Murphy

The OIG Toolkit To Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes is a valuable tool in your compliance arsenal. One you should be using if you’re at all involved with risk adjustment.

What is the Toolkit?

The toolkit offers Medicare Advantage Organizations (MAO) information that allows them to replicate the OIG’s techniques to identify and evaluate high-risk diagnosis codes to ensure proper payments and provide better care for enrollees.

In short, it’s the OIG’s auditing blueprint. Use it and you could save your organization hundreds of thousands or millions in fines.

What diagnoses are high risk?

As of November 2023, the OIG has found that approximately 70% of high-risk diagnosis codes were not supported in the associated medical records. The error rate of some groups of codes is as high as 90%.

Conditions and other groups at highest risk of error include the following:

  • Acute stroke, 96% error
  • Acute heart attack, 95% error
  • Embolism, 79% error
  • Lung cancer, 88% error
  • Breast cancer, 96% error
  • Colon cancer, 94% error
  • Prostate cancer, 89% error
  • Potentially mis-keyed diagnosis codes, 81% error

The Toolkit lists the associated ICD-10 codes underneath these groups so that you can drill down into specific problem areas.

Why are error rates so high?

The OIG reviewed thousands of claims for services that can be used for risk adjustment purposes, including physician, outpatient, and inpatient. It found that MAOs are reporting codes for active conditions or acute exacerbations when a history of is warranted.

In most cases, the medical records supported an old condition rather than acute. For example, a prior myocardial infarction diagnosis (which does not map to an HCC) instead of an acute myocardial infarction diagnosis.

One high-risk group included individuals who received a lung cancer diagnosis during a service year, but the encounters and the relevant PDE data did not indicate that the individuals received surgical therapy, radiation treatments, or chemotherapy drug treatments administered within a six month period either before or after the diagnosis. A history of lung cancer diagnosis is generally what was supported in the medical records, the OIG said.

A few seem to want to skirt the need for active monitoring or support but the OIG isn’t buying it.

If it wasn’t documented, it wasn’t done.

What should you do with the Toolkit?

The OIG hopes that the users of this toolkit will, at a minimum, use the information to detect and correct inaccurate diagnosis codes in their own systems.

Read it, disseminate the information with your coding staff, outpatient CDI/pre-visit chart review team, population health, your compliance officers, and of course your providers. Every one of these players has an integral role in accurate reporting of diagnosis codes, and their joint efforts can keep you off the OIG’s radar.

Review MEAT criteria and the proper use of history of codes.

Make sure your tech stack including point of care technology (i.e., auto-prompts to the physician) isn’t capturing codes without clinical support.

References

Need assistance? Contact us

Norwood Solutions offers compliance audits and risk mitigation. Contact us at solutions@norwood.com.

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