The Top Three MRA Mistakes: How much are these costing your practice?

When a medical group’s risk score is low despite a chronically ill patient population, the culprit is generally one of three very common practitioner habits. Let’s explore each one:

Failure to connect diabetic manifestations: This is probably the low-hanging fruit of the risk adjusted reimbursement world and one that’s relatively easy to fix. Diabetes is known for its devastating effects on the entire body, from the eyes to the kidneys, yet we lose track of the number of diabetics whose manifestations are not properly documented or coded by the provider. Peripheral Neuropathy in a diabetic warrants a more specific diabetes ICD-9-CM code (e.g., 250.6x); not only is this the most accurate code for the patient’s condition but when the patient’s diabetes has caused this neurological manifestation, the funding is adjusted as well. In this case, the missing connection results in decreased funding of $413.52 PMPM*.

Improper documentation of histories. The term ‘history’ is actually used in two manners by clinicians. In one sense, the history of a condition – for example, seizure disorder – can be documented to remind the practitioner that the patient had an episode of this condition in the past. It can also mean the patient has actually had the condition for some time and is receiving treatment. In most cases, this habit of documenting has been honed over time, but not only is it inaccurate, it also impacts the provider’s reimbursement. Practitioners need to understand that coding guidelines dictate that ‘history’ is generally coded as a condition that was successfully treated, no longer exists and is not a health threat to the patient. Using our example above, the ICD-9-CM code for history of seizure disorder is v12.49; the correct code for a patient under treatment for a seizure disorder is 345.9x. The funding difference is $270.61 PMPM* .

Un-specific cardiac disease. According to the American Heart Association, heart disease continues to be a leading cause of morbidity and mortality in the U.S. However, consider this diagnosis a general category – if you will – and one that is not used when more specific acute or chronic manifestations of heart disease are apparent. It’s akin to saying we live in the Milky Way Galaxy as opposed to Miami, Florida. Clinicians are reminded to consider the patient’s accurate cardiac status and document in a way that reflects the active conditions, even if stable and responding to treatment. From a funding standpoint, the difference between documenting the all-general (non-risk-adjusted) cardiac disease, as opposed to the more specific atrial fibrillation or cardiomyopathy is $296.96 PMPM* and $415.54 PMPM*, respectively.

* All funding estimates are based on a 75 year-old, community dwelling female in Dade County.

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