In this last blog in our four-part series on pitfalls, we thought we’d discuss the culture of your MRA department and how it guides the work. Our almost-20 years in this field have brought us into contact with practices and reviewers who span a long continuum. On one side is the practice whose directive is to increase MRA scores at all costs; reviewers who constantly identify new conditions are lauded. This, however, can be a slippery slope. We’ve lost track of the “creative” conditions suggested by some coders and how they strain credulity or are downright incorrect.
In addition, misunderstandings about the actual criteria of medical conditions can abound. We mean no disrespect when we say that sometimes that misunderstanding comes from providers themselves. They follow guidance from the coder in reporting diagnoses they are not convinced are valid. (Don’t scoff… we’ve seen and heard it first-hand!) One condition making its way around coding circles – to the future financial peril of medical practices – is the substance induced disorder. Scenario: the patient has insomnia. The patient drinks coffee. Coffee is a stimulant. Hence, the insomnia is due to the coffee drinking. Uhhhhh not so fast…. Read this blog on how that diagnosis category really works.
On the other end of the MRA department continuum is the team of reviewers that look for the basics: chronic conditions reported last year that are missing this year. That’s really just the bottom of the barrel in MRA work. There must be a balance between assuring long-standing, stable conditions are assessed and reported, and mining new documents to catch new conditions as they’re diagnosed.
Our company has occupied the risk adjustment space since 2004, its very early days, and we completely understand the financial implications of leaving money behind. We also know the pain of CMS recoveries that strip years of funding from a practice that reported unfounded conditions. The best philosophy for your MRA department is to identify all the conditions that are clinically indicated for your MA plan member and to assure that every risk adjusted condition you report is valid and properly documented. This is quite different from the objective of increasing MRA scores that has been management’s directive to more than one coder.
Increasing MRA scores is a finite exercise because although more than 10,000 codes are risk adjusted, the number of chronic conditions found in primary care is not ever-growing. Report all you know to be valid and make sure it’s well defended by the provider, both clinically and coding-wise. That’s the true key to success in MRA!