Connection supplemental articles and policies - November 2008

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Connection - Nov 2008 (pdf, 143 KB)

Supplemental articles

• CMS Medicare chart audit

Policies and forms

The following policies are new:

• Hospice Payment Policy
• Never Events Payment Policy
• Non-covered Services Payment Policy

The following policies have been reviewed and changes are indicated on each policy:

• Evaluation and Management Payment Policy
• Laboratory and Pathology Payment Policy
• Team Conferences and Telephone Services Payment Policy
• Vaccine Payment Policy

CMS Medicare chart audits

Common problems noted by independent auditors

In accordance with the 2006 Risk Adjustment Data Validation (RADV) audits, the Centers for Medicare & Medicaid Services has expanded their review of medical records to include a far broader sample size for selected entities. By law, CMS must review the records of one-third of all Medicare Advantage Organizations for any given data collection period.

Fallon Community Health Plan has provided a list of common chart documentation concerns as noted by staff and independent auditors during targeted 2007 chart reviews.

Here are examples of our chart documentation concerns:

• Assessments are not documented or are unclear.
• Progress notes are without a patient name or date of service.
• Progress notes are not signed or authenticated.
• Diagnostic tests results that confirm diagnoses are not incorporated into the progress notes.
• Patient is on medication, but documentation does not provide a diagnosis to support it.
• Diagnosis is inferred but not documented; for example, elevated blood sugar is documented instead of diabetes, and patient is on oral hypoglycemic agents.
• Patients with diabetic retinopathy need a clarification regarding proliferative or non- proliferative retinopathy.
• Notes do not clearly state cause and effect; for example, diabetes with diabetic nephropathy is noted, but not the diabetic etiology of the nephropathy.
• Diagnosis is found on problem list but is not documented in the audited year.
• Chronic condition is not documented.
• Use of abbreviations or symbols that are not standard.
• Provider’s notes and/or signature not legible.
• Provider’s credentials are missing.

If you have any questions regarding risk adjustment payment methodology, contact your Provider Relations Representative at 1-866-ASK-FCHP, option 4. Representatives from FCHP’s Medicare Reimbursement and Analytics Department are available to conduct presentations as appropriate.