A Medicare Risk Adjustment (MRA) coder is familiar with the guidelines established by CMS to conduct regular internal audits and is instrumental in ensuring a healthcare provider’s risk adjustment coding is not rejected.
Here are some of the most common chronic conditions and reasons for rejection:
· Substance Dependence
This condition was not validated because the physician did not document any DMS-5 criteria.
· Peripheral vascular Disease
PVD was not validated because no symptoms, no signs, no supported imaging were documented. Documentation of intermittent claudication or abnormal pedal pulse or an arterial Doppler showing atherosclerosis of artery of lower extremity will be enough to support this condition.
· Hemiplegia post stroke
Hemiplegia was not validated because the description given during the physical exam for the musculoskeletal system was contradictory since it was noted as normal. No unilateral muscular weakness was noted.
· COPD with exacerbation
Exacerbation refers to a flare-up or episode where the patient exhibits respiratory symptoms. This condition was not validated because the respiratory system was described as normal.
· Diabetic peripheral neuropathy
The reason of the non-validation was because the patient was asymptomatic, was not taking neuropathy medication, was not seeing any neurologist, and this neurological condition was not described as stable.
The consequence of the rejections will be:
a decrease of the patient's HCC score
And consequently, a reduction in reimbursement.
That is why the physician needs a MRA coder with good knowledge of clinical documentation.
Here is a good book that MRA coder can use to learn more about correct clinical documentation. Click on it:
https://amzn.to/3mIo2yZ
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