Category Archives: Risk Adjustment (MRA)
Billing No-Nos: Having the Billing Dept. Transact MA Encounters
Medicare Advantage (MA) plans are paid by the Centers for Medicare and Medicaid Services (CMS) based on the member’s severity of illness as conveyed by codes from the International Classification of Diseases, 10th Revision or ICD-10-CM that map to the … Read Full Post
Supporting a Diagnosis of Angina Pectoris
In a primary care setting, we sometimes encounter patients who have been diagnosed with angina pectoris and are being followed by the primary care practitioner (PCP). In this blog, we will share some of the most common issues regarding this … Read Full Post
“Not-Assessments:” Misconceptions about Assessing Conditions
We educate a good bit about documentation of a proper assessment, use the acronyms M-E-A-T or T-E-A-M and still see skimpy notes with an “assessment” that doesn’t pass muster – from providers who, by now, should be on board with … Read Full Post
MRA & The New Patient Visit
In our years of reviewing charts, we’ve observed new PCP visits where the clinician assigns diagnoses based on the medications the patient is taking, adds them to the problem list and includes them in the assessment of the visit. Let’s … Read Full Post
WWR – Kaiser agrees to pay $6.4 million to settle claims it received inflated Medicare Advantage payments
Kaiser joins the undignified ranks of the companies investigated for committing fraud. This timely article from Healthcare Finance News doesn’t use that word, but it describes the finding that Kaiser “knowingly submitted” false diagnoses to inflate its payments, which is … Read Full Post
Chronic Kidney Disease Stage 3
For 2021 coding, which begins on October 1, 2020, Chronic Kidney Disease Stage 3 (N18.3) was changed to N18.30 Chronic Kidney Disease Stage 3, unspecified (This code corresponds to Glomerular Filtration Rates (GFRs) between 30 and 59.) N18.31 Chronic Kidney … Read Full Post
Lessons from the Cigna/DOJ Lawsuit: Health Risk Appraisals (Part 2)
Last week’s first installment of this blog started our review of HRAs in the MRA environment. Let’s continue searching for lessons to apply in your practice. A third issue with Cigna’s HRAs was the supposed expectation to capture all the … Read Full Post
Compliance Tool-kit Should Include External Validation
Although all providers should have a Compliance Program, it seems that mostly larger groups have them in place and even then, to varying degrees. Many practices have some form of internal validation of a coder’s work; most of the time, … Read Full Post
Documentation for Risk Adjusted Payment
The concept of medical documentation has usually focused on those elements supporting the evaluation and management (E/M) code selection in fee-for-service payment environments; electronic medical records (EMRs) have done a great deal to alleviate the charting burden for these clinicians. … Read Full Post
Lessons from the Cigna/DOJ Lawsuit: Health Risk Appraisals (Part 1)
This blog is the first in a series of lessons, or reminders, gleaned from the Department of Justice’s (DOJ) lawsuit against health insurer Cigna. The suit alleges that Cigna essentially committed fraud by reporting false information to CMS in a … Read Full Post