OIG Releases “Medicare Advantage Compliance Audit of Specific Diagnosis Codes”

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS OIG Leave a Comment

OIG Releases “Medicare Advantage Compliance Audit of Specific Diagnosis Codes”

The Office of Inspector General released in January 2022 an audit report on Medical Advantage for Healthfirst Health Plan, Inc. The identified errors were related to some specific diagnosis codes and Hierarchical Condition Categories (HCCs).

Another Medicare Advantage Audit Report from the OIG! This particular audit report by the Health and Human Services (HHS) Office of Inspector General (OIG) was conducted on encounters from the Medicare Advantage (MA) organization, Healthfirst Health Plan, Inc. (Healthfirst), and focused on seven groups of high-risk error categories and diagnoses. We have seen an ongoing trend of OIG audits on MA Risk Adjustment encounters over the past several years, and documentation and coding accuracy continues to demonstrate gaps and areas for improvement.

Patient demographics and diagnoses are used to calculate the MA risk score for the individual beneficiary enrolled in Medicare Part C or Medicare Advantage program through a Medicare Advantage Organization or MAOs (insurance health plans). The Centers for Medicare and Medicaid Services (CMS) determines which diagnoses will be considered for risk adjustment, those with disease burden and risk that impacts ones health status. CMS also provides annual information regarding which ICD-10-CM codes are included in the MA risk adjustment calculation, which is through an algorithm and grouping process, the ICD codes are part of Hierarchical Condition Categories (HCCs).

According to this audit report, the OIG sampled Healthfirst unique enrollee-years with the high-risk diagnosis codes for which Healthfirst received higher payments for 2015 through 2016, so the data had both ICD-9-CM codes in addition to ICD-10-CM. The “seven high-risk” HCC errors relate to the following:

  1. Acute stroke (Cerebrovascular Accident/CVA)
  2. Acute heart attack (Acute Myocardial Infarction)
  3. Acute stroke and acute heart attack combination
  4. Embolism
  5. Vascular claudication
  6. Major depressive disorder
  7. Potentially mis-keyed diagnosis codes

Details of the above HCC diagnosis errors is available within the OIG summary and detailed audit report. You can access the OIG summary announcement at: Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Healthfirst Health Plan, Inc., (Contract H3359) Submitted to CMS A-02-18-01029 01-05-2022 (hhs.gov)

The complete detailed audit report is available at: https://oig.hhs.gov/oas/reports/region2/21801029.pdf

This certainly is another red flag for Compliance, HIM Coding and CDI professionals to take a look at this report and establish a plan for auditing and education on MA Risk Adjustment encounters. It’s important to follow along with the OIG audit reports and obtain insight into documentation and coding areas that have compliance risk vulnerabilities across the different healthcare settings.

MRA is available to provide assistance for auditing and education. Visit: https://www.mrahis.com

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