CRC Compliance and RADV Audits 2 — Questions and Answers
Question 1: During a RADV audit, an auditor reviews HCC 18 based on code E11.22. The chart shows 'diabetes with renal manifestations' but no mention of CKD. What is the likely outcome?
- HCC will be confirmed because diabetes with renal manifestations supports E11.22 (Correct answer)
- HCC will be deleted due to insufficient specificity
- HCC will be downgraded to HCC 19
- The audit will defer to the submitting organization
Correct answer: HCC will be confirmed because diabetes with renal manifestations supports E11.22
Documentation of 'diabetes with renal manifestations' generally supports a diabetic kidney condition and E11.22.
RADV audits evaluate whether submitted codes are supported by documentation. Stronger documentation explicitly stating 'diabetic CKD' would be less ambiguous.
Question 2: An MA plan discovers systematic upcoding of diabetes by a provider group. Under the False Claims Act, what element must be present for liability?
- Proof the plan directly instructed providers to upcode
- Knowledge of false claims or deliberate ignorance of their falsity (Correct answer)
- Evidence of actual financial harm to CMS
- Demonstration that every single claim was intentionally fraudulent
Correct answer: Knowledge of false claims or deliberate ignorance of their falsity
The FCA requires scienter: knowledge, deliberate ignorance, or reckless disregard. Specific intent to defraud is NOT required.
A plan that discovers systematic upcoding and fails to correct it could be liable under deliberate ignorance. The 60-day rule requires overpayments to be reported and returned.
Question 3: Which documentation practice presents the highest RADV audit risk?
- Templated notes with comprehensive review of systems
- Submitting diagnosis codes from problem lists not addressed in encounter notes (Correct answer)
- Multiple providers documenting the same condition differently
- Addendum notes added within 24 hours
Correct answer: Submitting diagnosis codes from problem lists not addressed in encounter notes
Unaddressed problem list entries are the highest risk because RADV auditors look for evidence conditions were actively evaluated during the encounter.
A condition only appearing on an unaddressed problem list is the most likely to fail RADV validation.
Question 4: What is the primary purpose of the RADV Fee-for-Service Adjuster?
- To increase payment recovery amounts
- To account for coding errors in the FFS benchmark that inflate the comparison baseline (Correct answer)
- To penalize plans with high error rates
- To adjust for regional coding variation
Correct answer: To account for coding errors in the FFS benchmark that inflate the comparison baseline
The FFS Adjuster recognizes that FFS Medicare also contains coding inaccuracies, leveling the playing field.
Without this adjustment, RADV would hold MA plans to a higher accuracy standard than the FFS system they are benchmarked against.
Question 5: A compliance officer identifies suspiciously high HCC 96 capture rates for a provider group. What is the appropriate first step?
- Immediately report to CMS
- Terminate the provider contract
- Conduct a targeted chart audit of a sample of HCC 96 claims (Correct answer)
- Apply a correction factor to future submissions
Correct answer: Conduct a targeted chart audit of a sample of HCC 96 claims
A targeted chart audit determines whether the high rate reflects accurate coding or a problem. Investigation must precede corrective action.
Statistical outliers can result from legitimate clinical differences, excellent documentation, or problematic coding. A targeted audit examines a sample to determine the cause.
Question 6: Which encounter type is NOT acceptable for risk adjustment diagnosis submission?
- Office visit with a physician
- Telehealth visit with audio and video
- Lab-only encounter with no face-to-face provider interaction (Correct answer)
- Home health encounter with a qualified provider
Correct answer: Lab-only encounter with no face-to-face provider interaction
Lab-only encounters without face-to-face provider interaction do not qualify. CMS requires diagnoses from encounters where a provider directly evaluates the patient.
Diagnoses from lab encounters cannot be submitted for risk adjustment. This prevents plans from generating HCCs from automated lab interpretations without clinical context.
CRC Compliance and RADV Audits 2
During a RADV audit, an auditor reviews HCC 18 based on code E11.22.
The chart shows 'diabetes with renal manifestations' but no mention of CKD.
What is the likely outcome?