Provider Resources

September Coding Tip Corner

Written by HealthTeam Advantage | Sep 19, 2022 12:53:11 PM

Why So Many Record Requests?
Each month, we address the need the Risk Adjustment department has for medical records. (You may think we sound like a broken…record!) We also recognize that many offices are short staffed and overwhelmed.

So why does the Risk Adjustment team always seem to be requesting medical records?

In short, our medical record requests are a result of the Centers for Medicare & Medicaid Services (CMS), Office of the Inspector General’s (OIG) requirements upon Medicare Advantage Organizations (MAO). Read on to learn about the different types of Medicare audits.

Diagnosis Code Capture
CMS requires MAO’s to participate in accurate diagnosis code capture to ensure that members’ chronic conditions are captured on a yearly basis. Each diagnosis code acquired in the prior year needs to be captured in the current year. The diagnosis codes paint a picture which allows the MAO to fully understand the health needs of our member, your patient. These record reviews can be very intensive to both your office and our team.

Here’s an example to illustrate the importance of this code capture. If your patient had an amputation of a toe in the prior year, the amputation acquired status ICD-10-CM needs to be recaptured in the current year. Essentially, if the amputation status acquired diagnosis code is not captured in the current year, it would appear to both the MAO and CMS that the toe grew back.

Improper Payment Measurement (IPM)
Additionally, each year, MAO’s are required to participate in at least one IPM audit. This is a targeted audit to determine if the diagnosis codes billed by a provider and sent to the MAO, which the MAO sends to CMS, are supported by clinical documentation.

Risk Adjustment Data Validation (RADV)
RADV audits allow CMS to perform audits on patients’ medical records to verify diagnosis codes that are tied to hierarchical condition categories (HCCs). The most recent audit targeted member-specific HCCs billed to CMS as well as a random audit of a member(s) HCC codes. These types of audits require a lot of medical records to validate the codes sent by providers to the MAO, which are submitted to CMS, are valid and supported by documentation.

Office of the Inspector General (OIG)
Over the past few years, the OIG has received referrals from CMS to determine if specific issues are a systemic issue or are considered a non-issue. When the OIG audits an MAO, it concerns the following:

  • Incorrectly submitted diagnosis codes for Acute Stroke, Acute Heart Attack, Embolism, or Major Depressive Disorder
  • Potentially miskeyed diagnosis codes
  • Other identified issues


Because the OIG is auditing the records the MAO submits to CMS, it is easy to notice that the diagnosis codes the MAO obtained were from a provider group or other organization.

These audits demonstrate our reliance on the provider community to document the condition and code for the condition correctly.

One audit performed on an MAO recommended that the MAO refund $197.7 million in overpayments to CMS and work to improve its policies to ensure compliance with federal requirements for diagnosis codes.

Making the Process Easier
Medical record requests can be quite daunting, but they are necessary. Our department is always looking for ways to make this process easier on your clinic.

One way we are trying to do this is by obtaining direct EHR access to allow us to download those chart notes, thereby eliminating your staff from the process. The other way is by trying to consolidate our audits into one bulk chart request.

Key tips to keep in mind when coding a diagnosis code:

  • If it’s not documented, it wasn’t done!
  • Remember coding to specificity is KEY.
  • Are you selecting a current code?
  • Validating the current Medical Problem List to ensure all conditions are valid and current. The most common condition we see appear when documentation supports the sequela condition: Acute CVA.