Medicare Risk Adjustment (MRA) is a double-edged sword. While it gives an incentive to take care of sicker patients who need more services and more care, the risk of audits and refunds are ever-looming. How to avoid this challenge ? Over the years, we have tried to follow these principles consistently to document all the conditions that a patient has but to do so compliantly and appropriately.
These are some of the principles of MRA compliance:
- MRA is team work: No one person should be responsible for this extremely critical function of any office that sees Medicare Advantage or Accountable Care patients. Every employee starting from the front to medical assistants to coders and billers and auditors need to be up on the latest changes with International Classification of Disease Codes (ICDs) and Hierarchical Condition Categories (HCCs) along with the elements that make a note complete, consistent, coherent and comprehensive. Physicians need to know the nuances of proper documentation of symptoms and signs for any diagnosis that may be relevant, referencing prior records, investigations and consultations from specialists along with addressing each diagnosis in assessment and plan and not just listing them to accrue HCC diagnoses. Why ? Because we are practicing preventive medicine. The sooner we connect all the dots, the better we can treat the condition, and perhaps keep it from getting worse.
- MRA compliance involves digging deep: The provider, scribe, advanced practitioners, nurses and medical assistants need to take a step back and ask questions in detail and allow patients and families or caretakers the space and time to provide details. For examples, I have found that many patients who deny alcohol consumption at present will readily admit to alcohol abuse or alcoholism in the past. The reason this is important is not only to snag a new diagnosis but also to have a full picture of the patient’s social history in the past which may be relevant to their health at present. Similarly, history of prior investigations or operations or biopsies must be probed diligently, thoroughly following each thread with as much specificity as possible. You are a detective... you need to connect the dots to get on top of what is actually happening.
- MRA compliance involves patience and systemic thinking: A lot of factors from patient’s history and exam will have relevance in their care. In my opinion, after a few visits complacence sets in and providers take the condition for granted. Thus, we miss conditions that may be obvious to anyone with a discerning eye. For example, peripheral neuropathy is often missed because it is not considered even by neurologists and podiatrists in patients complaining of imbalance or falls. Diagnoses are not connected with each other, e.g., ulcers with varicose veins, or non-healing ulcers with vascular disease or underlying infections, and one tends to work superficially, randomly, symptomatically. This tendency needs to be overcome consciously by the provider if he or she wants a note that attempts to look at the patients from all possible differentials in diagnoses. You cannot properly treat the patient if you don’t know what is going on with them. What are the underlying factors ? What led to them being in the predicament they are currently in? How can you prevent some of this from happening ?
- MRA compliance requires examining: Cursory exams should be avoided. A patient with blatant purpura might have underlying platelet deficiency or domestic situations that need to be addressed. Loss of weight unintentionally might signify significant conditions brewing or slow decline of the patient’s musculature and skeletal system due to poor intake or malnutrition. Everyone must pay closer attention to what is right under your noses.
- MRA compliance requires research, discussion and review: Constant learning by the team is critical. Discussions among subject matter experts and review of sources for diagnosis along with appropriate coding, review of processes in submission and gap analytics to ensure that the codes have reached CMS, in a granular manner will ensure that honest and precise work is rewarded and compensated for. Encounter Data Processing System (EDPS) and Risk Adjustment Processing System (RAPS) specialists are helpful in ensuring that codes are not lost in transit.
Above all……… say what you see. Don’t ignore anything. There is no such thing as too much information. And if you have a question, ask it.
Thus, a drilling down along with a review of each process, connecting all the dots by the clinical documentation team followed by operations and technical experts can ensure that the MRA records remain clear, succinct, concise and auditable to ensure the best care of our patients.