Kaiser Permanente is the latest Medicare Advantage (MA) plan to be embroiled in allegations of False Claims Act violations for risk adjusted coding activities. As you might recall, Humana was flagged for reporting unsupported risk adjusted diagnoses, Anthem allegedly failed to remove knowingly erroneous codes and Cigna was accused of fraudulently reporting conditions during its Health Risk Appraisal process. Kaiser is accused of pressuring providers to create invalid addenda to medical visits long after the encounter. The DOJ specifically states these addenda were created “often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements.”
In 2003-2004 – the early days of the CMS-HCC model – there was little guidance on the creation of addenda, and a 30-day time-frame from the date of the visit became the unofficial rule of thumb. Since that time, more specific direction has understandably narrowed the deadline, bringing it more into line with general medical practice.
Let’s backtrack for a few minutes. Risk adjusted conditions reported by providers form the bulk of payments from CMS to MA plans for their members. (Feel free to read the many blogs on our website for more background.) The specific conditions in the CMS-HCC model, which are assessed and managed by certain clinicians and reported to MA plans, result in higher payments because of predictive cost factors.
Conditions may only be reported when they’re assessed/addressed by the provider during a visit. We’ve said it before and we’ll say it again: risk adjustment is not about payment because the patient has a condition, but because the provider is managing it. And as we all know, the healthcare adage, “If it isn’t documented, it didn’t happen” is always true. Some providers try to get around this by creating an addendum to the note and reporting MRA conditions because they were not on the original note.
An addendum is a valid practice when information is appended to the original note because an assessment was begun during the visit, but additional information was still pending at its conclusion. Here’s an example: a member with signs and symptoms of a possible clot in his leg sees the PCP, who suspects a clot but needs imaging evidence to confirm it. On the date of the visit, the PCP codes what she knows for sure: just the symptoms (e.g., pain, swelling, etc.). She orders a stat test and receives a positive result on the following day. In this situation, the PCP can make an addendum to yesterday’s visit, date it with the day she received the result, explain the test result, new diagnosis, treatment and plan provided to the patient, and ask the biller to re-process the claim with the new information. The first key point is that the assessment of the condition (or symptoms) was begun during the visit and a critical piece of information was left pending. This information arrived quickly after the visit (second key point) – not months later – and the provider took action on it.
Most providers would argue that it’s best to see the patient again to deliver the test result and establish the treatment plan, or refer the patient elsewhere for treatment. While this is certainly at the clinician’s discretion, it’s also acceptable to discuss the information with the patient by phone and append the info to the note, thereby saving time.
Addenda may not be used to report risk adjusted conditions that were “forgotten” during the visit. We’ve seen this habit in operation and it ages us each time LOL Usually, a coder or biller realizes that a chronic condition has not been reported in the current period and asks the provider to add it to the note. Or, an administrator, acting on an MA plan’s reports of conditions “dropping off,” asks the provider to create an addendum. If this is occurring in your practice, you need to stop this immediately and conduct a widespread coding review. Audit every risk adjusted condition reported to make sure it has been properly assessed during the visit and promptly submit a removal report to the plan for any improperly reported codes.