The toolkit will help Medicare Advantage (MA) organizations improve the accuracy of submitted diagnosis that are at high risk for being miscoded.
The U.S. Department of Health and Human Services Office of Inspector General (OIG) today released guidance to help MA organizations identify and evaluate high-risk diagnosis codes to ensure proper payments and provide better care for enrollees. OIG said the toolkit contains information about the circumstances under which these diagnosis codes could be miscoded and the actual programming codes that the watchdog uses in its audits to identify them.
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The new guidance comes in the wake of audits of MA organizations that revealed certain diagnosis are at high risk for being miscoded to the Centers for Medicare & Medicaid Services (CMS) for use in its risk adjustment program. As of November 2023, OIG has found that, overall, approximately 70 percent of those diagnosis codes weren’t supported in the associated medical records. And some diagnosis codes were not supported more than 90 percent of the time.
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“Although the audited MA organizations usually disagreed with our reports' recommendations and with various aspects of our audit methodologies, those MA organizations generally did not disagree with our determinations regarding these diagnosis codes, and some expressed a genuine interest in submitting corrections to CMS. Other MA organizations—including ones that we have not audited—have asked us to share with them how we decided which diagnosis codes were at high risk for being miscoded,” OIG said.
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The watchdog said it hoped MA organizations will use the information about the process it follows to detect and correct inaccurate diagnosis codes in their own systems. In addition, OIG said it should be a starting point to identify other diagnosis codes that are at high risk for being miscoded and to take appropriate measures to prevent, detect, and correct such errors.
The 47-page toolkit includes:
- High-risk groups identified in OIG audits for incorrect diagnosis codes that were consistently submitted to CMS.
- Explanations that demonstrate why these specific diagnosis codes, when coupled with other data (including procedure codes and prescription drug events), are at high risk for being miscoded.
- Structured Query Language—a programming language used in many software programs—that OIG used in audits to query CMS' systems. The language and codes included relate to the 2019 payment year and organizations can use the codes to query its internal data systems to identify the enrollees in the various high-risk groups more accurately.