Documentation with RAD-V audit in mind

Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance

This is a two page document from CMS. The first page is a checklist and the second page provides guidance.

When a condition is on the Problem list, that condition should be assessed in the chart and not just coded from the problem list without further documentation. With electronic health records (EHR) there is much information that is just forwarded into the next visit, we can only assume it is current and complete.  Adding new "free text" with information regarding that date of service is desirable.

It is risky for medial coders to make assumptions that a particular medication on the chart was prescribed for an exact problem mentioned in the assessment.  Many times medications are prescribed for the side effect and not what it is typically used for.  We should try to avoid making our own conclusions on medications if not clearly referenced by the provider.  Our goals should be that the physician assess the condition, include the name of the medication prescribed and if the patient is currently taking the medication.  Just because it is prescribed doesn't mean the patient filled the prescription and is taking the medication.

We need to follow our company's policies and procedures on coding, but look at documentation in the light of it being in a RAD-V audit some day.  Would the documentation be very clear and specific to an auditor?  If not, we open up our liability to possibly returning funds on a future audit. We want to minimize that to the best extent possible.

https://www.cms.gov/Medicare/Medicare-Advantage/Plan-Payment/Downloads/radvchecklist.pdf

for google search:  Appendex 2 NAT13 RADV Medical Record Guidance.pdf

Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.