Improving diagnosis coding accuracy is a key objective for HHS-OIG, CMS, and Medicare Advantage (MA) Organizations. Recently, HHS-OIG unveiled the "Toolkit to Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes." Designed for health plans, providers, and others involved in risk adjustment, this Toolkit aims to enhance the accuracy of CMS-HCC model diagnosis codes submitted for payment, directly addressing a critical area in risk adjustment.
Understanding the Need for the Toolkit
The Medicare Advantage industry faces a significant challenge with the inherent risk of inaccurate diagnosis reporting during audits. To address this issue, HHS-OIG developed a targeted solution built on extensive audit experience. As of July 2023, HHS-OIG released twenty-two audit reports, each delving into the specifics of diagnosis codes submitted by health plans. These audits revealed sample overpayments ranging from $90K to nearly $700K, and after extrapolation, estimated overpayments spanning from $550K to $6.4M for enrollees with high-risk diagnosis codes.
Toolkit Overview and Components
The Toolkit provides a structured approach to identifying high-risk diagnosis codes, which is crucial for reducing a plan's audit risk and maintaining the overall integrity of the Medicare Advantage program. The kit includes a detailed list of high-risk diagnosis codes that are commonly prone to miscoding. These diagnosis codes fall into seven categories with very high error rates (see the figure below).
Figure: Errors in High-Risk Groups as of November 2023
(Reprinted from HHS-OIG Toolkit, December 2023)
| High-Risk Group | Total | Errors | Error % |
|---|---|---|---|
| Acute stroke | 945 | 908 | 96% |
| Acute heart attack | 791 | 751 | 95% |
| Embolism | 754 | 593 | 79% |
| Lung Cancer | 391 | 345 | 88% |
| Breast Cancer | 390 | 373 | 96% |
| Colon Cancer | 390 | 368 | 94% |
| Prostate Cancer | 360 | 322 | 89% |
| Potentially mis-keyed diagnosis codes | 522 | 421 | 81% |
| Totals | 4,543 | 4,081 | 90% |
Additionally, the Toolkit offers SQL query examples and logic to exclude enrollees from high-risk groups if there is valid evidence of treatment such as inpatient or outpatient encounters, specific procedure codes, and prescription drugs.
The Toolkit is extensive, featuring over 2,400 unique high-risk diagnoses. These codes are based on the 2019 payment year, aligned with the V22 CMS-HCC risk adjustment model. Despite changes in the models over time, a significant portion of these codes remains relevant for the 2024 payment year. With the introduction of the V28 model, where CMS has excluded many "discretionary codes," we took the initiative to verify the continued relevance of these high-risk codes. Our review found that only a small fraction of the Toolkit's codes are not included in the V28 model, mainly within the Potentially Mis-Keyed category, along with a few from the Acute Stroke group.
Practical Application of the Toolkit
The Toolkit is not just a compliance tool; it's an integral part of a comprehensive risk adjustment strategy. Health plans, providers, and vendors should promptly embed it into their operations. This strategy encompasses:
- Provider Documentation & Education: The Toolkit helps improve provider documentation and education, particularly in using "history of" diagnoses correctly. For instance, where an acute stroke diagnosis is used, a history of stroke might be more appropriate. Providers often mistakenly document and code conditions as acute or current, when they are, in fact, chronic or resolved conditions, which affects the accuracy of HCC payments.
- Provider Billing System Audit: Implementing incentives for providers to self-audit healthcare claims submissions is crucial. Given the billions of diagnosis codes received annually, it's nearly impossible for health plans to audit each one before CMS submission. However, using the Toolkit, providers, especially those submitting high-risk diagnoses, can more feasibly review their records, ensuring the correct usage of acute versus history codes.
- Health Plan Diagnosis Audits: Proactively submitting delete records to the Encounter Data System or the Risk Adjustment Processing System, as CMS requires, is key to reducing audit risk. The Toolkit enables plans to monitor submissions for high-risk diagnoses using the same logic as HHS-OIG, allowing for immediate medical record reviews to validate high-risk diagnoses and reduce overpayment risks. This approach also simplifies the process of identifying the right provider record for audit, as these diagnoses typically occur as one-time events.
Call to Action
The HHS-OIG Toolkit is a crucial asset for enhancing the accuracy of Medicare Advantage diagnosis codes. Its comprehensive nature makes it indispensable for any MA organization focused on refining risk adjustment data submissions. We urge Medicare Advantage organizations and others involved in risk adjustment to adopt the HHS-OIG Toolkit in their operations.
To further support our users, we're excited to announce an upcoming feature in Mscore™, our versatile CMS-HCC model software. This new feature will automatically flag HHS-OIG high-risk diagnosis codes, streamlining oversight and improving data accuracy for users of our Desktop, Command-Line, or API applications.
For personalized assistance or training on effectively utilizing the Toolkit and Mscore™, feel free to reach out to us. Together, we can enhance the precision of Medicare Advantage risk adjustment diagnosis codes.