OIG Audit Reveals Diagnosis Reporting Problems Affecting Risk Adjustment Scoring

by  Wyn Staheli, Director of Content - innoviHealth
Jun 15th, 2023

The Office of the Inspector General (OIG) recently published their Spring 2023 Semiannual Report to Congress. This report contained some diagnoses reporting issues that all providers need to be aware of. They focused on several groups of diagnoses that they considered “High-Risk” for being miscoded. Several states were included in the report and the types of errors for all can be generally grouped into the following:

1. 1. No Hospital Claim Data: Certain conditions typically require facility services (i.e., hospital inpatient or outpatient) within a certain time frame (e.g., 60 days before or after). If there was not a corresponding hospital claim, they stated that the claims should have used either a “history of” diagnosis code (e.g., Z86.73) or a less severe manifestation of the disease code instead. Although the report itself did not name particular diagnoses codes, the descriptions they included were:
      • Acute stroke
      • Acute heart attack
      • Acute stroke and acute heart attack combination
   2. Medication Missing or Mis-matched: For certain conditions, it is expected that a patient will receive medication during the year to manage that condition. The following diagnoses were often either missing medication claims or had a different type of medication prescribed:
      • Major depressive disorder: Antidepressant medication should have been received by the patient. Also, be aware that there is now an unspecified code (F32.A) where there used to only be code F32.9 so be sure to review claims where code F32.9 was used to ensure that diagnostic criteria have been met.
      • Embolism: An anticoagulant medication is typically prescribed and would have been received by the patient. In these instances, a diagnosis of history of embolism (an indication that the provider is evaluating a prior acute embolism diagnosis that does not map to an HCC) typically should have been used.
      • Vascular claudication: The patient has received medication that is frequently dispensed for a diagnosis of neurogenic claudication — NOT vascular claudication. They also looked at the preceding 2 years to see what diagnoses were assigned during that time to look for incorrect coding not supported by the medical record.
   3. Missing Treatments: When a patient has a listed diagnosis of cancer (within a certain time period of that diagnosis) certain treatments during that year were expected to also be a part of the patient’s medical record, including but not limited to, surgical therapy, radiation treatments, or chemotherapy drug treatments. In these instances, a code for “history of cancer” that does not map to an HCC code (e.g., Z85.118, Z85.3, Z85.038) should typically have been used.
      • Lung cancer
      • Breast cancer
      • Colon cancer
      • Prostate cancer
   4. Potentially mis-keyed diagnosis codes: Some diagnosis codes can be easily transposed causing a data entry error and thus a wrong code is entered which then potentially maps to an incorrect HCC. One example in the report was “ICD-9 diagnosis code 250.00 (which maps to the HCC for Diabetes Without Complication) could be transposed as diagnosis code 205.00 (which maps to the HCC for Metastatic Cancer and Acute Leukemia and in this example would be invalidated).” Using data analytic tools, they compared all reported diagnoses codes for a patient and then used algorithms to flag those that might be a mis-match.

Now that we know which diagnoses are receiving increased scrutiny, take time to perform an internal audit to review claims with these diagnoses and ensure that they have been properly coded.