Term
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Definition
Is the record for the correct enrollee?
Is the record from the correct calendar year for the payment year being
audited (i.e., for audits of 2011 payments, validating records should be from
calendar year 2010)
Is the date of service present for the face to face visit?
Is the record legible?
Is the record from a valid provider type? (Hospital inpatient, hospital
outpatient/ physician)
Are there valid credentials and/or is there a valid physician specialty
documented on the record?
Does the record contain a signature from an acceptable type of physician
specialist?
If the outpatient/physician record does not contain a valid credential and/or
signature, is there a completed CMS-Generated Attestation for this date of
service?
Is there a diagnosis on the record?
Does the diagnosis support an HCC?
Does the diagnosis support the requested HCC? |
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Term
| This checklist list was provided to plans involved in the calendar year(s) |
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Definition
(CY) 2009 and CY 2010 national
RADV audits. |
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Term
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Definition
performed after the information has been reported
In RA, typically reviews prior year |
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Term
RADV Audit
Medical record must support: |
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Definition
Dx code
Document must be signed
Treating provider signature
Attestation for missing signature or credential |
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Term
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Definition
| Extrapolation is a veritable tsunami in Medicare/Medicaid audits. The auditor collects a small sample of claims to review for compliance, then determines the “error rate” of the sample. For example, if 500 claims are reviewed and one is found to be noncompliant for a total of $100, then the error rate is set at 20 percent. That error rate is applied to the universe, which is generally a three-year time period. It is assumed that the random sample is indicative of all your billings, regardless of whether you changed your billing system during that time period or maybe hired a different biller. In order to extrapolate an error rate, contractors must use a “statistically valid random sample” and then apply that error rate on a broader universe of claims, using “statistically valid methods.” |
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Term
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Definition
| Current year's values impact next year's payments |
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Term
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Definition
| Be aware that some organizations will pick up chronic "lifelong, incurable" conditions if stated in PMH |
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Term
RA coders must be able to code:
only HCC codes?
All ICD10 codes |
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Definition
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Term
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Definition
The word “with” or “in” should be interpreted to mean “associated with” or
“due to” when it appears in a code title, the Alphabetic Index (either under a
main term or subterm), or an instructional note in the Tabular List. The
classification presumes a causal relationship between the two conditions linked
by these terms in the Alphabetic Index or Tabular List. These conditions
should be coded as related even in the absence of provider documentation
explicitly linking them, unless the documentation clearly states the conditions
are unrelated or when another guideline exists that specifically requires a
documented linkage between two conditions (e.g., sepsis guideline for “acute
organ dysfunction that is not clearly associated with the sepsis”). |
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Term
| Location of ICD10 guidelines |
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Definition
| cdc.gov/nchs/icd/icd10cm.htm |
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Term
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Definition
Monitor
Evaluate
Assess
Treat |
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Term
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Definition
Treatment
Assessment
Monitoring/Medicate
Plan
Evaluate
Referral |
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Term
Section III.A. Previous Conditions
Inpatient |
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Definition
"If the provider has included a diagnosis in the final diagnostic statement, such as the
discharge summary or the face sheet, it should ordinarily be coded. Some providers
include in the diagnostic statement resolved conditions or diagnoses and status-post
procedures from previous admission that have no bearing on the current stay. Such
conditions are not to be reported and are coded only if required by hospital policy.
However, history codes (categories Z80-Z87) may be used as secondary codes if the
historical condition or family history has an impact on current care or influences
treatment." FY2020 ICD10 Guidelines pg 111 |
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Term
Section III.B. Abnormal Findings
Inpatient |
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Definition
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not
coded and reported unless the provider indicates their clinical significance. If the
findings are outside the normal range and the attending provider has ordered other
tests to evaluate the condition or prescribed treatment, it is appropriate to ask the
provider whether the abnormal finding should be added.
Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
FY2020 ICD10 Guidelines, pg 111 |
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Term
Section III.C. Uncertain Diagnosis
Inpatient |
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Definition
If the diagnosis documented at the time of discharge is qualified as “probable,”
“suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,”
“compatible with,” “consistent with,” or other similar terms indicating uncertainty,
code the condition as if it existed or was established. The bases for these guidelines
are the diagnostic workup, arrangements for further workup or observation, and initial
therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute,
long-term care and psychiatric hospitals.
FY2020 ICD10 Guidelines, pg 111 |
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