Since 2004, our company’s MRA work has undergone significant evolution, and we’ve worked on everything from isolated projects for a one-time client, to daily or annual reviews and even to serve as a client’s MRA Department. We presented some of this information in a blog series entitled Pitfalls in Chart Reviews during Spring 2022, and in this series, we’ll flip the script and look at overall perspectives for the MRA department’s work.
Let’s start with facts – not facts with a small ‘f’ but facts, almost in all caps. What are the facts that guide the work done by your MRA dept, specifically when it comes to recognizing, suggesting and querying diagnoses? We could regale you with stories from the trenches of conditions proposed by coders and reported by providers that have little to no basis in fact, or conditions reported because someone at some health plan said you should.
When something is rooted in fact, it can be put in writing by the sayer – with no angst. After all, if you’re going to risk your practice’s funding by reporting a condition whose payment can be recouped years into the future, make sure your source is solid. That doesn’t mean your source may not be wrong, or the plan or CMS may disallow the condition for other reasons, but at least you’ve done your due diligence in striving for accuracy and you can back up your actions. If the individual is reluctant to provide you with written information about the proposed code, heed the warning bell and reconsider your actions.
In terms of medical conditions, there is a great deal of lore that affects a coder’s recognition of a possible risk adjusted condition, but – as they say – consider the source. Our company spends a great deal of time researching scholarly sources (more on that in a second) and conferring with licensed physicians to understand – as much as possible for laypeople – the hallmarks of certain conditions. Perhaps we take this requirement to heart because our company is a vendor and we have a responsibility to our clients to back up our work with vetted information; the same is not usually true of the medical practice MRA coder, who may feel free to implement what his friend at [fill in the blank] is doing because the rep from [fill in the blank] said they could. And sometimes those blanks are big-name medical groups or plans, which could lead you to think you’re being too narrow minded or ill informed. Before you cave to the pressure, take a look at some of our blogs on OIG cases involving “big names” who have paid back millions in recoveries to the federal government for, among other things, improper coding and reporting conditions for which there is no evidence.
Anyone can set up a website and publish misinformation, and just because it’s out there doesn’t make it true. That’s why we stick to sources such as medical journals, medical texts, and organizations like the American Diabetes Association, Alzheimer’s Association, etc. – in other words, no dot-coms. All of our bulletins and guidance to clients list the sources we consulted because we have no problem naming names. And after we’ve done that, we confer with clinicians to fill in gaps and operationalize the information.
Consider re-evaluating the methodology your practice employs when hearing about “new” conditions to code, or new connections among diagnoses that happen to yield higher payments. Put the brakes on eager coders or providers and do your research. Discuss the information with relevant individuals in your practice, seek clinician input and establish parameters for reporting those conditions. When a large number of your patients seem to have a condition with low prevalence in the medical literature, something’s wrong with this picture.
Join us for Part 2 of this blog series where we’ll continue our discussion on best practices for your MRA work.