HCPro, JustCoding Inpatient - 2022 Issue 27 (July)
Healthcare News: OIG audit targets high-risk diagnosis codes
July 5th, 2022
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Article Overview
This article summarizes an Office of Inspector General audit involving diagnosis coding used in CMS risk adjustment and the resulting overpayment findings for a Medicare Advantage organization. It is relevant to coders, compliance staff, auditors, and managed care professionals who monitor diagnosis documentation, risk adjustment integrity, and federal program requirements. The piece covers the audit’s focus areas, the population reviewed, the financial impact, and the OIG’s recommended corrective actions at a high level.
Why This Topic Matters
The article highlights how auditing of diagnosis coding can lead to significant overpayment findings and compliance actions in Medicare risk adjustment. It matters to organizations that submit diagnosis codes for risk-based payment and need to maintain documentation support and internal review processes.
Article Sections
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Audit overview
Introduces the OIG review of diagnosis coding in a Medicare risk adjustment context and the organization involved.
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High-risk diagnosis groups reviewed
Summarizes the broad categories of diagnosis groupings the audit examined and the method used to identify higher-risk claims for review.
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Review population and payment impact
Describes the sample reviewed, the scope of payment amounts associated with the audit, and the overall financial impact reported.
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Audit findings and recommendations
Covers the compliance findings at a high level and the corrective actions recommended by the OIG.
What You Will Learn
- How an OIG audit can focus on diagnosis coding in Medicare risk adjustment
- What broad categories of diagnosis groups were reviewed
- How audit findings can translate into overpayment and compliance concerns
- What types of corrective actions are commonly recommended after audit results
Who Should Read This
- Medical coders
- Compliance officers
- Risk adjustment professionals
- Auditors
- Medicare Advantage operations staff
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