Risk Adjustment (RA) is a payment methodology used by the Centers for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS) to adjust payments to Medicare Advantage and Marketplace plans, such as those offered by Quartz. Payment made to Quartz by the federal government is based on the enrollee’s health status and demographic characteristics. Accurate chart documentation and diagnosis coding determines reimbursement to health plans.
Quartz’s Risk Adjustment Department routinely conducts retrospective medical record chart reviews to ensure accurate and complete coding. Inaccurate and incomplete diagnosis coding can result in overpayments or underpayments from CMS. Overpayments are a result of payment received from CMS for a diagnosis code that is not supported in the medical record whereas underpayments are a result of additional diagnosis codes found in the medical record that were not included as a diagnosis on the claim.
Each quarter, the errors identified are shared with our providers in an effort to improve future coding and documentation. Listed below are some identified trends upon completing first and second quarter 2019 chart reviews.
Overpayments Identified – Coded but not documented
- Morbid Obesity
- Acute Myocardial Infarction
- Ischemia or Unspecified Stroke
- Pulmonary Embolism and Deep Vein Thrombosis
Underpayments Identified – Documented but not coded
- Diabetes with Chronic Conditions
- Metastatic Cancers
- Cardio-Respiratory Failure and Shock