Health Status Validation Success. Did you know that HHS-RADV Audits are more claims focused and centered around a specific and acceptable claim? Are you sure that your team can survive this non-traditional audit, and have correctly focused their review efforts?

Centauri Health Solutions’ Director of Coding Services- Monica Watson

To say that Monica Watson is passionate about all things coding, would be a huge understatement. As Centauri’s Director of Coding Services, Monica Watson, has more than 15 years of hands-on experience leading coding and auditing operations for Medicare and commercial Risk Adjustment and Facility coding. She has created and maintained coding best practices for diagnosis coding abstraction in ICD-9-CM and ICD-10-CM and has designed and implemented Initial Validating Auditor programs.

As a trusted member and partner, Ms. Watson teamed up with the American Health Information Management Association (AHIMA) to create a series of articles focused on auditing medical record coding best practices. Below, we have reprinted the article in full, with permission from AHIMA. 

HHS-RADV Audits for Benefit Year 2016: Part 2

By Monica Watson, RHIA, CPC, CCS, CCS-P, CPMA, CIC, CRC

As autumn quickly approaches, so does the 2016 initial validation audit (IVA) season, formally known as the Health and Human Services-operated Risk Adjustment Data Validation (HHS-RADV). This second year of the audits, the Centers for Medicare and Medicaid Services (CMS) has determined, will be another pilot year, allowing all parties to continue to work out the kinks and improve the process and outcomes. CMS spent the better part of the last few months listening to participants of the 2015 Benefit Year HHS-RADV and other key parties, gathering feedback and learning about pain points, which has resulted in improvements and clarifications to assist in a more successful year-two pilot.

The goal of the HHS-RADV is to validate Hierarchical Condition Categories (HCCs) submitted on the EDGE server, ensuring that what was reported is supported. The health record review and coding workflow within the audit is called the Health Status Validation. CMS issues a protocols document outlining each aspect of the review, along with specific steps and criteria for completing them. There have been enhancements and updates to the process and CMS has provided more detail and clarification for this year’s audit.

The Health Status Validation includes the claims validation, the health records validation, and the HCC validation. In contrast to the traditional CMS-RADV for Medicare Advantage plans, HHS-RADV audits are more claims focused and centered around a specific and acceptable claim. The Health Status Validation requires a health record to be coded at least twice:

  • Primary Coder Review – Every health record will go through a primary review whereby the coding professional evaluates the documentation and abstracts diagnosis codes. Diagnoses are then mapped, or collated, to an HCC as applicable. Any HCC considered to be discrepant requires a senior coder review. A discrepancy in this audit process is defined as an HCC that is Unsupported or is New for the enrollee.
  • Senior Coder Review – Discrepant medical records will go through the senior coder review process, whereby the senior coding professional conducts the code abstraction and review using the same methods as the primary coding professional. This process ensures the accuracy of the identified discrepancy.  The senior coding professional’s outcomes are final and are eligible for submission in the final package.
  • IRR – Every medical record that does not go through senior coder review, and has all HCCs validated, will require Inter-Rater Reliability (IRR). A random sample of each primary coding professional’s validated HCCs is selected for review by a senior coding professional. Primary coding professionals are required to achieve an accuracy rate of 85 percent or better to pass the IRR sample. Primary coding professionals who do not meet the accuracy requirement on the first sample will have a second sample selected, up to a 100 percent sample, based on the total number of HCCs the primary coding professional validated.

A few key factors will ensure the Health Status Validation is a success.

  • All coding professionals should be certified and experienced in ICD-10-CM coding. It is preferable that coding professionals also have experience in risk-adjustment coding, as they will have a foundational understanding of HCCs and the concepts surrounding their capture.
  • CMS has said that the HHS-RADV will not use concepts such as Monitoring, Evaluating, Assessing/addressing, or Treatment (MEAT) to substantiate diagnoses, as the Medicare Advantage CMS-RADV does. The HHS-RADV will, however, focus on the use of the ICD-10-CM Official Guidelines for Coding and Reporting and Coding Clinic for ICD-10-CM and ICD-10-PCS. These two will be their acceptable references for diagnosis code abstraction as supported and utilized by the Secondary Validation Audit (SVA) in conducting their oversight validation.
  • The audit encompasses 2016 dates of service, which span two ICD-10-CM fiscal years. The 2017 Official Guidelines for Coding and Reporting, effective for discharges on or after October 1, 2016, added some key updates crucial to correct coding. Providing coding professionals with both 2016 and 2017 ICD-10-CM code manuals along with AHA Coding Clinic access will arm them to achieve maximum accuracy.
  • Finally, sharing the Health Status Validation and IRR components of the 2016 Benefit Year HHS-Operated Risk Adjustment Data Validation Protocol document will offer coding professionals the ability to conceptualize and understand the workflow in its entirety, providing ownership and insights into the work they are doing and how it impacts the final results.

 

REFERENCES

American Hospital Association. 2012-2017. Coding Clinic for ICD-10-CM and ICD-10-PCS.

The Centers for Medicare and Medicaid Services (CMS). The Center for Consumer Information & Insurance Oversight. Available at https://www.cms.gov/cciio/.

CMS. Registration for Technical Assistance Portal. Available at http://www.regtap.info.

National Center for Health Statistics. ICD-10-CM Code Set and ICD-10-CM Official Guidelines for Coding and Reporting. Available at http://www.cdc.gov/nchs/icd/icd10cm.htm.

 

Monica Watson (monica.watson@centaurihs.com), is the director of coding services at Centauri Health Solutions.

This article was published in AHIMA’s monthly CodeWrite newsletter—a benefit of AHIMA membership. If you would like to subscribe, consider becoming a member of AHIMA to get all the benefits of membership, and be part of a network of health information management professionals more than 103,000 strong.

 

About Centauri Health Solutions

Centauri Health Solutions focuses on revealing care opportunities through its suite of products and services. Delivering data-driven services, through private cloud-based software solutions, the firm provides comprehensive data management designed specifically for risk adjustment and quality-based revenue programs, in addition to enrollment and eligibility solutions. Centauri improves member outcomes and financial performance for health plans, hospitals and at-risk providers by supporting initiatives in health care enrollment, risk adjustment, RADV risk mitigation, HEDIS and Star Ratings. Headquartered in Scottsdale, Ariz., Centauri Health Solutions also has offices in Cleveland, Ohio, Nashville, Tenn., and Orlando, Fla. For more information, visit www.centaurihs.com.