Important Reminders from Risk Adjustment

The Risk Adjustment Data Validation Audits (RADV) will continue for quite some time. We ask for both your patience and full cooperation. This is a time-sensitive issue.

While there is nothing at this point that can be done to rectify the current errors that are seen in the documentation, it is extremely important to correct these moving forward.

Telehealth Flexibilities Ending Soon

Legislation extended certain Medicare telehealth flexibilities through September 30, 2025.

Currently, there are no plans to extend this action any further.

Therefore, provider offices should plan that the deadline will remain September 30, and schedule encounters as of October 1 to be face-to-face encounters.

Points to consider during the visit:

• All diagnoses that are assessed, evaluated, or treated during the visit, even if they are stable, should be properly documented
• Each documented diagnosis requires four elements (remember MEAT):
  • Monitored: Document the patient’s signs, symptoms, disease progression, or regression
  • Evaluated: Document the results of tests, medication effectiveness, or response to treatment
  • Assessed/Addressed: Document the ordering of any tests, discussions with the patient, review of records, or counseling
  • Treatment: Document the treatment provided for the condition, including medications, therapies, or other modalities

What are the requirements for a medical record to pass an RADV audit?

Complete and Accurate Documentation 

• Complete Medical Records: Auditors require records to be clear, transparent, and contain all necessary information to support the billed services and diagnoses 
• Support for Submitted Diagnoses: Any diagnoses submitted to Risk Adjustment must be clearly supported by the documentation within the patient’s medical record  
• Compliance with Coding Guidelines: Documentation and coding must align with the International Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting 
• Inclusion of Essential Information: Records should contain the correct beneficiary information (legal name is required), acceptable provider type, source physician specialty, dates of service within the data collection period under review, and valid signatures and credentials 

Supporting Documentation for Specific Record Types 

• Inpatient Records: Must include admission and discharge dates, and a signed discharge summary 
• Stand-alone Consultations: Need to contain the consultation date 
• Stand-alone Discharge Summaries (as physician provider type): Must include the discharge date 

Secure and Efficient Record Retrieval and Submission 

• Secure Exchange: Records should be exchanged securely, potentially through integration with EHRs, but also potentially via fax, email, or mail 
• Centralized Data View: The retrieval technology ideally should integrate data into a centralized view, enabling the identification of inconsistencies, data gaps, or errors, according to www.reveleer.com

Timely Submission

• Adherence to Deadlines: Health plans are given 25 weeks to submit medical records to CMS after an audit request

CMS is significantly expanding its audit program for Medicare Advantage (MA) plans. The new policy includes auditing every MA contract annually and reviewing a larger number of records.

Reminder: ALL chronic conditions must be addressed at least once a year, as well as Social Determinants of Health!