Last month, the Office of Inspector General published the report of a compliance audit conducted on one of Anthem Community Insurance Company, Inc.’s Medicare Advantage (MA) contracts. The OIG concluded that Anthem was overpaid by $3.4 million.
MA plans’ payments from the Centers for Medicare and Medicaid Services (CMS) are based largely on the anticipated cost of providing medical care to a group of enrollees. This is called risk adjusted payment. A large portion of the payment is calculated by assessing the future costs of certain medical conditions attributed to the member and which map to hierarchical condition categories (HCCs). As with many CMS payment programs, risk adjustment is prospective so that the conditions identified and reported for the member in one year form the CMS payment to the plan in the following year. To give you an example of the magnitude of these payments, the report states that for the 2015 and 2016 payment years – the period being audited – CMS paid Anthem $2.3 B to provide coverage to 137,000 enrollees.
The OIG has a responsibility to audit government payment programs and identify areas of waste, fraud and abuse. It identified seven HCCs at higher risk for miscoding and conducted an audit of a random sample of members for whom the associated conditions were reported. Let’s look at these problem-prone conditions.
Acute stroke. Strokes are coded at the time they occur, which means they are coded one time. Once the acute event is over, the patient may have other complications from the stroke, which are coded when evaluated by a clinician, but the stroke itself is referred to as having occurred in the past. Past conditions are communicated in the language of “history codes,” which are rarely risk adjusted. In the case of strokes, ICD-9-CM (in effect at the time of the OIG audit) guidelines required reporting a history of cerebrovascular accident (or stroke). OIG found that 80% of the time, acute strokes were reported when they were really histories. In one case, the medical record supported stroke as a differential diagnosis.
Differential diagnoses are “working diagnoses;” they are not confirmed. Instead, they are possible conditions for which the provider will test and evaluate the patient. Many times, clinicians have several differential diagnoses, which they narrow down as evidence becomes available to point them toward one confirmed condition.
In seven percent of the cases reviewed, there were no records to support the stroke diagnosis (acute or history).
Acute heart attack. As we know, the term acute, denotes something that happens suddenly and is of relatively short duration. Similar to strokes, acute heart attacks are coded at the time they occur. In the world of ICD-9-CM coding, however, an acute myocardial infarction, as it’s called, can be coded for the first eight weeks following the event; this means that for a period of time, the provider can and should report the acute code even if the heart attack isn’t occurring at that moment. There is no such guideline for strokes. In 63% of the cases in the OIG audit, the condition was coded as acute well beyond the eight weeks. At that time, the “old MI” code was risk adjusted and would have provided a smaller payment, but the correct code was not was not submitted for payment. For 20% of the cases, no evidence existed at all for acute or old MI.
In a small number of cases, acute stroke and acute MI were coded together with no support for any reported case.
Embolism. Embolism HCCs include conditions such as pulmonary embolism (PE) and deep vein thrombosis (DVT); the former is an acute event and the latter can be either acute or more infrequently, chronic. An embolism is a clot and when patients develop this condition, which is evident on imaging studies, they are treated with clot-busting drugs and usually, a six-month course of anticoagulants to prevent recurrence.
Many providers believe that for the period of time the patient is being anticoagulated, they can report the acute embolism codes. This is incorrect. There is no eight-week guideline as with acute MI. Emboli are coded when they occur and for the short time the clot is being dissolved, which experts says is approximately two weeks. After that, for the duration of the anticoagulation therapy, the correct code is “history of,” which is not risk adjusted. If the clot returns, there will be imaging evidence and the acute or chronic code can be used once again, depending on the evidence. The OIG report states that Anthem reported incorrect codes in two-thirds of the cases reviewed.
Vascular claudication. The most common condition in this category is peripheral vascular/arterial disease (PVD), which can be reported from a physical examination or from imaging evidence. In a little more than 25% of the cases, the OIG audit concluded that the reported condition could not be validated.
Major depressive disorder (MDD). This HCC includes not only MDD, but bipolar disorder and schizophrenia. Psychiatric conditions are diagnosed based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM). The OIG reported that in 20% of the cases, the reported condition was not supported. Check out our YouTube video on MDD and the misunderstandings that lead to its mis-coding.
Mis-keying. The OIG found that in almost 70% of a different sample of cases, coding errors resulted from mis-keying or transposition. Some examples cited include reporting 205.00 (leukemia) instead of 250.00 (diabetes), and submitting 482.0 (pneumonia) instead of 428.0 (heart failure).
As expected, Anthem challenged many aspects of the OIG audit that concluded Anthem had been overpaid by $3,468,954 and the OIG refuted each of the plan’s claims. However, the issue remains that coding errors do happen and in the aggregate, result in gross overpayments. Some are the result of misunderstandings by providers, such as reporting strokes long after they occur, and others are due to human error.
All organizations, including small medical practices, must perform compliance activities to assure their coding is accurate and the documentation in medical records is available to support the conditions reported. Coding can be reviewed for errors by simply examining a sample of problem-prone codes that are easily transposed and checking claims against progress notes. When errors are found, the plan or provider is duty-bound to request their removal from the payment system, something Anthem wasn’t too keen on doing as reported last summer.
Faulty understanding of the required evidence for a medical condition, however, can be perpetuated throughout the organization. For this reason, audits to validate the support for conditions should be conducted by a third-party who can also educate the practice on areas for remediation. Better to do this yourself than after a large-scale audit that recoups your funding.