Holly Cassano - CPC, CRC, AAPC, ICD-10-CM Certified Tags: , , , , Coding, Compliance
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A wise man once said “The beginning is the most important part of the work.” I couldn’t agree more, that wise man was Plato, from his work, The Republic.

It’s Third Quarter of 2017 and the Medicare Advantage (MA), Plans are ramped up and ready to begin a third set of “HCC Sweeps”, for the year.  The beginning of each “sweep” period, by United, Humana, Freedom, Aetna and all the other players in the pond, should start with ensuring they have Certified Remote HCC (CRC – Certified Risk Adjustment Coders), coders in-house or remotely employed and this year, leave the novices at Risk Adjustment Coding, to train for the following year, instead of onboarding them now.  In light of recent DOJ developments.

The recent allegations by the Department of Justice (DOJ) are significant, the DOJ has made has alleged, based on audit results, that some MA Plans have been involved with upcoding of diagnoses codes that exaggerated the severity of illness of some members. This led to much higher weighted HCCs and in turn more money from CMS to the plan, for that member annually.  Please click on the following links for further information:

United Healthcare, organized and implemented a company wide upcoding scheme, which United called “Project 7”. United implemented it as an attempt to significantly improve its overall operating income by close to $100 million

An excerpt from Sheppard Health Law, states that the lawsuit alleges that back in 2010, United Healthcare, organized and implemented a company wide upcoding scheme, which United called “Project 7”.  United implemented it as an attempt to significantly improve its overall operating income by close to $100 million. The scheme, tasked their coding team to purposely code patients for “high risk”, “long term” chronic diseases, via data mining of their participating provider member panels for any evidence/mention of any of these within the medical record. The problem is that when the coders found these conditions, many have been alleged to not have the required face to face visit. The DOJ also alleges that United provided incentives to participating providers, in order to have them code members for higher severity chronic conditions than what was originally diagnosed.  Please click on the following link for further information:

The DOJ case cites 15 insurers, currently, the DOJ is seeking to intervene only on FCA violations which involve United and its subsidiary. United Healthcare currently services upwards of 3 million CMS members/beneficiaries, has denounced the DOJ allegations and contends that these anomalies occurred due to inaccurate interpretations of CMS Risk Adjustment rules.


Let’s say you are a Primary Care Doctor, with a few providers in your practice.  You participate in several MA Plans and you receive a letter with a list of your patients from the MA Plan asking you to verify some “conditions/diagnoses” that their coders/auditors/software, etc., noticed might be current Chronic Conditions.

What they are really asking is if you can quantify these “more severe Chronic Conditions”, like Congestive Heart Failure, or Diabetes with Neuropathy, or Chronic Kidney Disease Stage 4 or higher, as they have somehow been a part of the patients reported past disease history or there is a medication prescribed that could indicate one of the Chronic Conditions being sought for validation by the MA Plan.

The reason for this, is so that if the patient definitely has these conditions, you as the provider, need to correctly report these to the MA Plan, at minimum once per year, so that the Plan can receive enough money from CMS to cover that member’s costs.  It is not a large profit margin for the plans, so they chase every dollar possible.  Which is why you get these letters requesting you review charts or requests to allow their staff into your EMR to comb the patient records to look for “missing/dropped” diagnoses.

The downstream effect of all this is now that United, Humana, Freedom, Aetna and others are under investigation by the DOJ, is there could be potential practice audits, depending on what comes out as the cases move forward.

It all boils down to the data collection process, which of course always points back to the physician’s office and the documentation of the patient encounter.

Related webinar: Risk Adjustment and RADV Audit webinar video


Risk Adjustment reimbursement is driven by the accurate capture of ICD 10 (depending on the year, some ICD 9), codes.  This is what CMS utilizes to calculate how much an MA Plan is reimbursed for submitted claims.  The data is mainly taken from provider claims submitted to the plan and also in sweeps, where MA Plans data mine member records from providers on their panels.

The HCC codes must be captured every 12 months for CMS to reimburse the MA plan, and if the HCC codes are captured outside of that scope of 12 months (for example, 12 months and 4 days), it will then generate a 6-month revenue gap for that MA plan

Diagnoses from the previous year are used to establish payments to the MA plan. The HCC codes must be captured every 12 months for CMS to reimburse the MA plan, and if the HCC codes are captured outside of that scope of 12 months (for example, 12 months and 4 days), it will then generate a 6-month revenue gap for that MA plan.


Physicians who do not exercise good documentation at each patient encounter with the chronically ill will receive fewer resources from health plans and will have less ability to grow and can be subject to audits, as are the MA Plans.

Good documentation begins at the time of the patient’s face-to-face encounter with the physician. It means the physician documents the clinical findings in the medical record, and the medical record is used to determine ICD-10-CM codes. The pertinent information from the patient encounter is submitted to the MA organization for payment.


The risk adjustment diagnosis must be based on clinical medical record documentation from a face-to-face encounter.

  • Coded according to the ICD-10-CM Guidelines for Coding and Reporting; assigned based on dates of service within the data collection period.
  • Submitted to the MA organization from an appropriate risk adjustment provider type and an appropriate risk adjustment physician data source.

What is the answer and what can you as a Provider do within your practice to ensure that the codes submitted to these MA Plans under investigation are correct?  Here is a list of best practices to ensure that your practice’s HCC/ICD 10 diagnosis coding is accurate:

THE WHO/WHAT/WHEN OF MEAT:   Was the condition Monitored, Evaluated, Assessed or Treated?

All conditions captured must be supported by MEAT or the required specific MEAT for certain conditions (e.g. cancer, MI, CVA, TIA, PE, etc.) What does MEAT stand for?

  • MONITOR—Signs, Symptoms, Disease Progression, Disease Regression
  • EVALUATE—Test Results, Medication Effectiveness, Response To Treatment
  • ASSESS/ADDRESS—Ordering Tests, Discussion, Review Records, Counseling
  • TREAT—Medications, Therapies, Other Modalities

TIP:  A minimum of one of the above MEAT components is required

TIP:  Some conditions require specific MEAT to confirm new or active status (e.g. Cancers, MI, CVA, TIA, etc.) or Manifestations, ie Diabetes with Neuropathy

TIP:  Adhering to M.E.A.T. requirements is Mission Critical.  Noncompliance with documentation requirements can lead to legal and financial risks to the health plan, the company, the providers, and coders!

There are a variety of downfalls that can beset providers and MA plans when confronted with a RADV audit. Everyone should remember is that when the provider follows the MEAT guidelines the documentation is basically audit-proof.

The best way to do this is by understanding the top 10 ways providers fail to meet RADV audits guidelines. The following is a composite list of what every provider and plan’s review for compliance with CMS risk adjustment guidelines should include:


  1. Failing to capture HCCs at least once every 12 months.
  2. Failure to ensure the medical record contains a legible signature with credential. For example, determine whether such as the electronic health record was unauthenticated (not electronically signed).
  3. Failure to ensure the diagnosis codes being billed and the actual medical record documentation match.
  4. Failure to document according to the M.E.A.T. principles. Diagnoses need to be monitored, evaluated, assessed/addressed, and treated.
  5. Failing to annually document status Z codes and chronic conditions.
  6. Failing to use a linking statement or document a causal relationship for manifestation codes.
  7. Failing to add any diagnosed HCCs or RxHCCs (prescription drug HCCs) to both the chronic problem list and the acute assessment.
  8. Failing to evaluate each of the HCCs/RxHCCs on a semiannual basis for updates.
  9. Failing to review all specialist documentation related to cardiology, master discharge summaries, radiology, specialty correspondence, pulmonary, echocardiograms, and x-rays, laboratory results, and previous encounters.
  10. Failing to submit more than the standard four ICD-10-CM codes (CMS allows up to 12, check with your EMR and clearinghouses on what they can accept)


The providers key to successful and compliant relationships with MA Plans is to remember, that at the end of the day, documenting the face to face encounter accurately.  That means you as the provider must provide timely and accurate documentation of all current, existing chronic conditions in your members and submit 1500’s electronically with more than the standard four ICD 10 codes, when they exist.  When the MA Plans receive accurate and timely claims information from participating providers, it allows the Plan to receive appropriate reimbursement from CMS, which in turn allows the plans to provide better premiums per member per month (PMPM) to providers and ultimately, provide overall improved benefits to members.

I Skate To Where The Puck Is Going
— Wayne Gretzky

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Holly worked for BillingParadise as one of our Regional Directors of RCM, Risk Adjustment, and Quality & Client Services, She was invited by the AAPC to be one of 7 people in 2014, to help develop The CRC National Credential & Exam. She is our resident Risk Adjustment Subject Matter Expert amongst other specialties.

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