CMS conducts annual RADV audits to ensure risk-adjusted payment (HCC) integrity and accuracy. The purpose is to identify any payment errors by having the MA organizations and their corresponding providers to submit specific requested medical records to validate the risk adjustment data or HCCs. So if a specific claim is included in the RADV audit, and it has a code for say, Diabetes Type 2 E11.9, they will review the chart note to see if it was appropriately documented. An errors can result in funds being returned to CMS.
This document list the specifics around RADV audits.
The latest RADV Medical Record Guidance
For auditing commencing after 01/10/2020, Version 2.0
https://cms.gov/files/document/medical-record-reviewer-guidance-january-2020.pdf
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/Coders_Guidance.pdf
RADV Medical Record Reviewer Guidance
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Prior guidance on audits commencing after 09/27/2017
'Contract-Level Risk Adjustment Data Validation - Medical Record Reviewer Guidance as of 09/27/2017
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/Coders_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.
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