11/14/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
Contract-Level Risk Adjustment Data Validation
Medical Record Reviewer Guidance
In effect as of 03/20/2019
*
This guidance will be used for audits commencing after 09/27/2017.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
2
Table of Contents
Table of Contents ........................................................................................................................................................................................................2
Introduction .................................................................................................................................................................................................................6
Purpose..................................................................................................................................................................................................................7
MA Organization Pre-Review of Submissions ..................................................................................................................................................8
Submission Review upon Receipt for RADV ....................................................................................................................................................9
Table 1: Attestation Issues .............................................................................................................................................................................11
Table 2: Submission Intake Issues .................................................................................................................................................................13
Enrollee name does not match medical record ..............................................................................................................................................13
Multiple medical records submitted in a single medical record file ..............................................................................................................14
Medical Record Review .............................................................................................................................................................................................14
Signature and Credential Issues ..................................................................................................................................................................….15
Table 3: Signature and Credential Issues .......................................................................................................................................................17
No Signature (or Initials) ...............................................................................................................................................................................17
Electronic Signatures .....................................................................................................................................................................................18
Unacceptable Electronic Signatures ..............................................................................................................................................................19
Point of Service EMR ....................................................................................................................................................................................20
Incomplete Electronic Signature ....................................................................................................................................................................20
Other Signature Verification Documents .......................................................................................................................................................21
Consultation Reports ......................................................................................................................................................................................22
Office Note Referencing Unsigned Dictated Report .....................................................................................................................................23
Signature Stamp .............................................................................................................................................................................................23
Signature Location .........................................................................................................................................................................................24
Physician Initials ............................................................................................................................................................................................24
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to
medical record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting
medical records be clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the
International Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set
forth in Medicare regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
3
Illegible Signature without Legible Credential ..............................................................................................................................................25
Other Credentials ...........................................................................................................................................................................................25
Date Issues ........................................................................................................................................................................................................26
Table 4: Date Issues .......................................................................................................................................................................................27
Undated Visit .................................................................................................................................................................................................27
Signature Date ................................................................................................................................................................................................27
Lack of Discharge Date .................................................................................................................................................................................27
Dictation Date ................................................................................................................................................................................................27
Dates of Service outside Data Collection Period ...........................................................................................................................................28
Date Located on Encounter Label ..................................................................................................................................................................29
Referral Responses .........................................................................................................................................................................................29
Provider/Record Type Issues ............................................................................................................................................................................30
Table 5: Provider Type/Record Issues ...........................................................................................................................................................30
Face to Face Visit ...........................................................................................................................................................................................30
Stand-alone Discharge Summary ...................................................................................................................................................................32
Non-face to face Visit ....................................................................................................................................................................................33
Diagnostic Testing (with or without interventional procedures) with acceptable provider interpretation ....................................................34
Technical Component Only ...........................................................................................................................................................................36
Clinical Laboratory Test Results ...................................................................................................................................................................37
Pathology Reports-with pathologist interpretation ........................................................................................................................................37
Pathology Reports-laboratory test only ..........................................................................................................................................................38
Telephone or Telemedicine/Video Contact ...................................................................................................................................................39
Emergency Department (ED).........................................................................................................................................................................40
Observation Visits ..........................................................................................................................................................................................41
Problem Lists (within a medical record) ........................................................................................................................................................42
Skilled Nursing Facility (SNF) ......................................................................................................................................................................43
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to
medical record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting
medical records be clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the
International Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set
forth in Medicare regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
4
Health Risk Assessments (HRAs) .................................................................................................................................................................44
Referral Authorization Forms ........................................................................................................................................................................44
Order Forms Documenting an Encounter ......................................................................................................................................................45
Prescription Forms .........................................................................................................................................................................................46
Certified Clinical Nurse Specialist .................................................................................................................................................................46
Therapists .......................................................................................................................................................................................................47
Other Specialties or Credentials .....................................................................................................................................................................47
Other Unacceptable Source Documents ........................................................................................................................................................49
•
List of ICD-9-CM codes ..........................................................................................................................................................................49
•
Claim forms .............................................................................................................................................................................................49
•
Hospice care ............................................................................................................................................................................................49
•
Home Health ............................................................................................................................................................................................................ 49
Other Documentation Issues ....................................................................................................................................................................................52
Chronic and other additional diagnoses ..........................................................................................................................................................52
Underlying Conditions ...................................................................................................................................................................................54
Previous Conditions .......................................................................................................................................................................................54
Abnormal Findings ........................................................................................................................................................................................55
Uncertain Diagnoses ......................................................................................................................................................................................55
Other Physician Documentation ....................................................................................................................................................................56
Table 6: Documentation Issues ......................................................................................................................................................................58
No Exam, Reason for the Encounter, or Condition Documented ..................................................................................................................58
Illegible Diagnosis – Handwriting .................................................................................................................................................................59
Illegible Diagnosis – Document Image ..........................................................................................................................................................59
Non-English Documentation .........................................................................................................................................................................60
Abbreviation with Multiple Meanings ...........................................................................................................................................................60
Medical Record Amendments ........................................................................................................................................................................61
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to
medical record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting
medical records be clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the
International Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set
forth in Medicare regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
5
Query Forms ..................................................................................................................................................................................................62
Missing Pages ................................................................................................................................................................................................63
Medical Record Documentation is Distorted or Obscured ............................................................................................................................64
Medical Record Documentation is Too Dark or Too Light ...........................................................................................................................64
Pages or Margins of the Medical Record are Cut Off....................................................................................................................................64
Appendix A: What Makes a Medical Record Invalid for RADV? ..........................................................................................................................65
Appendix B1: Acceptable Physician Specialty Types Program Year (PY) 2014 – Numeric ..................................................................................67
Appendix B2: Acceptable Physician Specialty Types PY 2014 – Alphabetic .........................................................................................................68
Appendix C: Glossary and Abbreviations ................................................................................................................................................................70
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
6
Introduction
The Contract-Level Risk Adjustment Data Validation (RADV) Medical Record Reviewer Guidance has been created to provide information on the
RADV medical record process. These guidelines are used by coders to evaluate the medical records submitted by plans to validate audited diagnoses.
Centers for Medicare & Medicaid Services (CMS) is legislatively mandated to risk adjust Medicare Part C payments and report a Medicare Part C
payment error rate. By regulation, CMS conducts annual RADV audits to ensure risk-adjusted payment integrity and accuracy. CMS’ Contract-Level
RADV audit initiative is the agency’s primary strategy to address the payment error rate for the Medicare Advantage (MA) program. The RADV
audit is conducted pursuant to regulations under 42 CFR § 422.310 – Risk adjustment data, section 422.310(e): “MA organizations and their
providers and practitioners will be required to submit a sample of medical records for the validation of risk adjustment data, as required by CMS.
There may be penalties for submission of false data.”
CMS selects a subset of Part C contracts for each annual RADV audit cycle. Enrollees are sampled from each selected MA contract to estimate
payment error related to risk adjustment. Once the enrollees have been selected, the MA Organization is required to submit medical records to
support all CMS-Hierarchical Condition Categories (HCCs) in the sampled beneficiaries’ risk scores for the payment year. For risk adjustment
purposes, CMS refers to the MA model of disease groups as HCCs. The CMS-HCC assigned to a disease is determined by the International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes submitted during the data collection period. Only
selected diagnosis codes are included in the CMS-HCC model. The term “hierarchical” in HCC refers to the ranking of these disease groups, or
“hierarchies,” based on the relative factor (weight) assigned to the HCC. Hierarchies allow CMS to pay for only the most severe manifestation of a
disease when diagnoses for less severe manifestations of a disease are also present in a beneficiary during the data collection year. A chart showing
the HCCs involved in hierarchies for the 2014 calendar year, along with an example of how payments were made with a disease hierarchy, can be
found on page 73 of the 2014 Rate Announcement.
MA Organizations may appeal eligible medical record review determinations and RADV payment error calculations for their selected contracts via
an administrative appeals process. CMS regulations require MA Organizations to adhere to established RADV audit procedures and RADV appeals
requirements. Failure to follow CMS rules regarding the RADV medical record review audit procedures and RADV appeals requirements may render
the MA Organization’s request for appeal invalid.
To validate the audited CMS-HCCs for sampled enrollees, the MA Organization must request medical records from hospitals (for Hospital Inpatient
and Hospital Outpatient records) and physicians/practitioners (for Physician records) that provided services to the selected enrollees; this document
will refer to those hospitals, physicians, and practitioners collectively as “providers.”
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
7
Purpose
This guidance focuses on areas impacting those RADV submissions with apparent documentation issues that could impact the validity of the medical
record when submitting it to confirm an audited CMS-HCC. The lack of these validity elements will result in an error under the RADV medical
record review process leading to a discrepancy for the audited CMS-HCC findings.
Each medical record correctly submitted with a matching sampled enrollee CMS coversheet is evaluated independent of all other submissions and is
reviewed for both validity and diagnosis coding. The entire medical record is reviewed before making a final decision on validity and coding. Only
RADV coding results from valid medical record submissions are used to substantiate payment. Invalid or a lack of a medical record submitted will
potentially impact the payment error calculation. It is critical to understand all guidance pertaining to these documentation issues will be considered
on a case-by-case basis. The guidance and examples are not exhaustive in content. Topics, guidance, and actions have been included based on
experience of prior RADV samples, but medical records can be unique in format, legibility, content, organization, etc.
The reviewers must first apply their expertise in documentation and official coding guidelines to each scenario. This guidance is organized in tables
addressing the validity of medical record submission and attestations regarding enrollee name, signature, credentials, date of service, provider type,
and other documentation issues. This guidance does not give advice for specific diagnosis coding; it does not contradict the ICD-9-CM Official
Guidelines for Coding and Reporting. CMS reiterates the purpose of those official guidelines.
“These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be
reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the
application of all coding guidelines is a difficult, if not impossible, task.” ICD-9-CM Official Guidelines for Coding and Reporting, page 1.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
8
At a minimum, medical records must meet the following requirements to avoid a discrepant finding:
• Correct beneficiary as provided on the CMS RADV coversheet
• Acceptable risk adjustment provider type, source, and physician specialty providing the face to face encounter
• Dates of service within the data collection period under review
• Valid signatures and credentials
◦
For outpatient or physician encounters, a CMS-Generated RADV Attestation form may be submitted to authenticate (with signature and
credential) the entries. The RADV Attestation form is provided with the MA Organization enrollee sample file. The attestation form is not for
validating dates or diagnoses.
• Coded according to the official conventions and instructions provided within ICD-9-CM, the ICD-9-CM Official Guidelines for Coding and
Reporting, and guidance provided in the “AHA Coding Clinic for ICD-9-CM” published quarterly by the American Hospital Association. Refer only
to issue dates effective at the time of encounter.
MA Organization Pre-Review of Submissions
Once medical records are received from the providers, the MA Organization should review the records internally to determine if the records meets Risk
Adjustment (RA) policies and if the documentation supports one or more of the audited CMS-HCCs. The MA Organization does not have the option to
change or amend any medical record documentation at the time of the RADV audit. Requesting that the provider change or amend a medical record at the
time of the audit does not meet requirements for timely medical record completion made at or near to the provider encounter and may have legal
implications. CMS understands the constraint when provider medical records are incomplete or documented inadequately. Therefore, the RADV process,
which is described in detail in submission instructions sampled MA Organizations receive, allows for multiple medical record submissions from multiple
approved providers from any encounter date in the data collection period, even if a diagnosis from that encounter was not previously submitted to
Medicare.
The MA Organization must select at least one medical record to support each audited CMS-HCC being validated. For the purposes of RADV audits, a
medical record is required to be documentation of a single face to face encounter for physician/practitioner office and hospital outpatient visits or a single
admission for hospital
Important Resource: ICD-9-CM Official Guidelines for Coding and Reporting are found at
https://www.cdc.gov/nchs/data/icd/icd9cm_guidelines_2011.pdf. This document includes ICD-9-CM Conventions (definitions of abbreviations,
punctuations, symbols and terms), guidelines for each code range (primarily by body system) chapter, Reporting of Additional Diagnoses, and
Diagnostic Coding and Reporting Guidelines for Outpatient Services.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
9
Inpatient stays. The medical records must be selected from an inpatient (IP) hospital, outpatient (OP) hospital, or physician specialty that is
acceptable for risk adjustment (see Appendix B: CMS-HCCs and Physician Specialties). The CMS Centralized Data Abstraction Tool (CDAT)
generates a Medical Record Coversheet for each of the sampled enrollees. The coversheet includes pre-populated contract information and enrollee
identification plus sections to designate the CMS-HCC(s) and date of service for the attached medical record. If the MA Organization finds more
than one medical record (from multiple provider types and/or dates of service) to support a given audited CMS-HCC, a separate Medical Record
Coversheet in CDAT must be completed for each medical record (i.e., a single date of service [Physician or Hospital Outpatient] or a single
admission [Hospital Inpatient]).
When MA Organizations receive records from providers, they should:
• Verify both the CMS RADV Medical Record Coversheet enrollee name and date of birth for every record received;
• Confirm all pages of every record are for the correct enrollee (if any page contains protected health information (PHI)/personally
identifiable information (PII) of another person, remove that portion before attaching the medical record for submission into CDAT);
• Confirm the date of service is clearly documented and within the data collection year;
• Confirm the provider type, specialty, and face to face requirement is clearly documented; and
• If no attestation was received and the provider name and credential are not clear on the medical record, re-request the provider legibly indicate
their name and credential and include another CMS RADV attestation form in the follow-up request.
Submission Review upon Receipt for RADV
Once the coversheets and medical records are submitted through CDAT, there is a process to perform an initial check on the submissions. This
process is referred to as the intake process. The RADV intake reviewers will initially check that
• The medical record submission is not completely blank;
• The name on the Medical Record Coversheet matches the name on the medical record:
◦
If the name on each page of the medical record does not match the coversheet, this could mean a possible PHI/PII data breach. Further
submission review is suspended if escalated for potential PHI/PII breach;
• Each submission contains one Medical Record Coversheet:
◦
Medical Record Coversheet is correctly labeled “CY 201X (review year) Contract-Level RADV” on all pages
◦
All data fields in Section I contain data
◦
All data fields in Section II contain enrollee data that matches the name on the medical record submitted. The birth date may be used as a
secondary identifier for common shortened names if it is present on the medical record. Note if the correction area has been populated to
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
10
explain any name variance.
◦
Section III, IV, and V are populated as directed with one radio button selection and at least one CMS-HCC indicated. If any unusual format or
population issues are noted, the RADV intake reviewer may escalate the case for confirmation to a Senior Evaluator (SE) who will submit a
support ticket if indicated. For CON14 reviews:
◦
The Discharge Date Year of Review field for a Hospital Inpatient record is populated with “2013”
◦
The Year of Review field for a Physician/Specialist/Hospital Outpatient/Observation record is populated with “2013”
◦
All fields in the Medical Record Submission Information section (File Name, Submitted By, and Submission Date) contain data
◦
On page 2, the Coversheet displays the ICD-9-CM codes that correspond to the audited CMS-HCCs selected within Section IV of the
Coversheet
• The CMS Attestation, if indicated, as attached is present and valid:
◦
Attestation is in the CMS Attestation format.
◦
The CMS-Generated Attestation must be completed, signed, and dated by the physician/practitioner who provided those services. No other
forms of an attestation will be accepted. The completed fields must include the printed physician/practitioner’s name, the date of service of
the medical record to which they are attesting, the physicians/practitioner’s specialty or credential, and must be signed and dated by the
physician/practitioner that encountered the face to face visit.
◦
Date ranges or multiple dates of service cannot be entered on a Medical Record Coversheet from an outpatient record. A CMS-Generated
Attestation may be completed by the attending physician/practitioner for a single date of service. If the date of service on the submitted CMS-
Generated Attestation does not match the medical record submitted by the MA Organization with the Medical Record Coversheet, it will be
deemed invalid and will result in an error under the CMS RADV medical record review process if the medical record lacks the necessary
physician/practitioner signature and/or credentials.
◦
If the attestation is invalid, the reviewer will flag for Invalid Attestation and select the appropriate invalid reason. Multiple reasons can be
selected.
Invalid Attestation Reasons in CDAT include:
1.
Attestation Altered
2.
Attestation Incomplete
3.
Date of Service Mismatch
4.
Incorrect Enrollee – Enrollee name does not match both coversheet and medical record
5.
Inpatient Record
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
11
6.
Non-CMS Generated Attestation
7.
Other – Include specific comment
8.
Unacceptable Credentials
9.
Unacceptable Signature – this includes attestation signed by someone other than the physician/practitioner with or without explanation
(retired, expired, Power of Attorney, etc.)
The following table presents examples of various attestation issues and how they are evaluated. Date examples are for audits that will be conducted on
payment year 2014 (CON14), dates of service in 2013.
Table 1: Attestation Issues
What the Reviewer
Might Encounter
Examples/Comments Acceptable for CON14
(Y/N)
A. Physician/practitioner signed
for another or signature stamp
used
1.
I, John Smith signed by Jane Doe, MD.
2.
“I am completing this form because John Doe is not available.”
3.
Name does not match the record without any explanation. Compare
handwriting to the extent possible, denying only blatant differences
when no printed name is available in the medical record.
4.
If first name matches but last name does not, escalate to Quality
Assurance (QA) Panel for guidance.
5.
John Smith, Power of attorney for Jane Doe, MD.
Include a comment “attesting name does not match physician/
practitioner name.”
N
B. Marked through
physician/practitioner name
attesting to his/her own record.
John Doe is marked through. James Dean is entered, and the attestation is
signed James Dean, MD. The medical record is assumed to be that of
James Dean, not that James Dean is signing for John Doe.
Y
C. Marked through date of service
Jan. 01/31/2013 (21 is written above or below the incorrect day 31).
Y
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
12
The following table presents scenarios the submission reviewers may encounter and what actions are indicated. See Appendix A for the complete list of
invalid (INV) flags with definitions.
Table 2: Submission Intake Issues
What the Reviewer
Might Encounter
Examples/Comments Acceptable for CON14
(Y/N)
D. Blank form
Name, Date of Service, or signature line is blank. For blank credential
line, see letter L. below.
N
E. Date of service handwriting error
(Date of Service is written over.)
Y
F. Date of service outside the
data collection period
12/30/2012 or 01/25/2014.
N
G. Partially illegible date of service
01/H/2013 It could be “4” or “11.” (Choose the one that matches the
medical record.)
Y
H. Date range
Jan. 1–Dec. 31, 3/4/13–5/6/13 (a date range).
Y/N
Pass only if Medicare Record
(MR) matches the first or last date.
I. Invalid risk adjustment
physician/practitioner
credentials
Medical Assistant, Licensed Practical Nurse (LPN), Dietician.
N
J. Multiple individual dates
of service
1. May 1, May 10, May 15, 2013
2. May 1–3, May 6, May 12, 2013
Y/N
(Only accept the date that
matches MR date of service.)
K. Wording of attestation
crossed out or added to
Attestation becomes invalid
N
L. Credential area is blank,
illegible, or not a common
credential
MSN (Master of Science in Nursing), “Provider.”
Escalate to a more senior coder
for review.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
13
What the Reviewer Might Encounter Actions
One Medical Record Coversheet ‘erroneously’ submitted with incorrect
medical record. The whole medical record or document within the medical
record clearly is not for the same enrollee designated on the coversheet.
A.
Entire medical record does not match.
B.
A portion or one document within correct submission is for a different
person.
C.
The name matches but the date of birth is significantly different (not a
likely data entry error and no correction indicated on coversheet).
•
The coversheet correction area is reviewed to see if the difference has
been identified by the MA Organization.
• PHI/PII breach protocol is followed. If the PHI/PII breach is
confirmed, the submission will be removed during the next CDAT
maintenance window.
If no breach, comment is entered regarding the acceptable name
difference.
Enrollee name does not match medical record. The name (and DOB
when available) on the coversheet does not match the medical record or
portions of the medical record.
Examples:
Lack of a name on a full report such as inpatient progress notes, multi-
part emergency department (ED) record forms, single or multi-page
transcribed reports.
A multi-part continuous form with the enrollee identification on at least one
page.
• Check the coversheet correction area. If correction area is filled in,
note the change in the variation of name comment.
• If the name is completely different, escalate to initiate PHI/PII
protocol.
• If the name is the same but birthdate is completely different (not just a
typo), escalate to initiate PHI/PII protocol.
• If the name appears to be a nickname or other variation, escalate and
enter comment regarding acceptance decision in the comment area so all
levels will be able to view the decision.
• Generally, any report within a multiple page record without a name
will not be reviewed, but these are handled on a case-by-case basis.
• If the documentation flows to each page and the reviewer can
reasonably determine it is the same patient, it can be reviewed.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
14
Medical Record Review
Medical record pre-review should be performed on all records received by the MA Organization from their providers. A cursory review of the first
page by someone not experienced in medical record documentation and coding is not sufficient. CMS RADV reviewers are certified coders,
experienced in risk adjustment data validation that are familiar with a variety of medical record layouts, electronic medical record entries, and
handwritten medical record documentation.
The following table presents issues that may impact the MA Organization’s decision to submit the medical record, potential follow-up with the
provider to obtain an attestation or additional documentation, and guidance on the action auditors may use to evaluate and resolve the issue. The listed
examples and guidance are not exhaustive, and all are continuously evaluated for consistency in interpretation and application.
What the Reviewer Might Encounter Actions
Multiple medical records submitted in a single medical record file
(with one Medical Record Coversheet).
•
If all medical records are not dated in the data collection year, the
record is flagged invalid for date of service outside data collection
period (INV14=NO).
• Whenever a submission contains multiple records with dates of
service in the data collection period, the submission is reviewed to
determine 1) which date of service to review and 2) which pages to
review.
◦
The coversheet date and validity (selecting a date of service that
documents signature, credential, etc.) of each of the medical
records will be considered in the decision.
• The reviewer will note the date of service selected for review in the
date validity comment area (INV4=YES).
• During coding, if the HCC can only be validated from another valid
encounter with a date not indicated on the Cover Sheet or in the INV4
comment, the submission will be reset to intake and the new date will be
reviewed.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
15
Signature and Credential Issues
Instructions Received by the MA Organization
Excerpt from CY 2013 Contract-Level RADV CMS Submission Instructions (Chapter 3, Section 2).
Medical records submitted for RADV must be from an acceptable physician specialty type (see Appendix 3: Reference Materials: CMS-HCCs and
Physician Specialties) and must be authenticated by the provider. MA Organizations must ensure the provider of service for face to face encounters is
appropriately identified on medical records via signature and physician specialty credentials. This means the credentials for the provider must appear
somewhere on the medical record (e.g., next to the physician/practitioner’s signature or pre-printed with the physician/practitioner’s name on the
practice’s stationery). If the credentials of the physician/practitioner are not listed on the stationery, then the credentials must be part of the signature for
that physician/practitioner.
Acceptable physician/practitioner authentication comes in the form of handwritten signatures and electronic signatures. Stamped signatures are not
acceptable. Signature logs may not be attached to correct records that have a missing or illegible signature. In these cases, please use the CMS- Generated
Attestation for the Physician/Practitioner office or Hospital Outpatient visit.
• Transcribed reports – Electronic signatures are an acceptable form of medical record authentication so long as the system requires the provider to
authenticate the signature at the end of each note. Examples of acceptable electronic signatures include: “Electronically signed by,” “Authenticated
by,” “Approved by,” “Completed by,” “Finalized by,” and “Validated by.” In all cases, the signature must contain the physician’s or practitioner’s
name and credentials along with the date signed, which must be within 180 calendar days of the encounter. Electronic signatur
es dated greater than 180
calendar days from the encounter date must include a valid CMS-Generated Attestation in order for medical record review to continue. (Note: CMS-
Generated Attestations can be submitted for Physician/Practitioner and Hospital Outpatient medical records only.)
• Electronic Medical Records (EMRs) – Electronic point of service type medical record entries are typically considered authenticated at login since the
physician/practitioner is directly entering the content into a template and populating from other sections of the EMR. Often only the provider name
will be documented at the beginning or end of the note, without the “electronically signed by” dated notation. Since EMR formats differ, the presence
and significance to RADV of a signature authentication statement and a date in a signature line depends on the structure of the EMR.
• Handwritten provider signatures on paper medical records need not have an accompanying signature date. CMS attempts to associate each signature
with a date of service on the record. Accordingly, please be sure each signature is clearly associated with a date of service for the note in question.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
16
Instructions Received by the MA Organization
• All medical record entries must be complete and must be authenticated by the physician or practitioner who was responsible for ordering, providing,
or evaluating the service furnished. The author of each entry must be clearly identified and must authenticate his or her entry. Regardless of the
provider type, a consultation report with the typed name of the dictating physician/practitioner should be signed by that physician/practitioner. For
purposes of this RADV, “promptly” is defined as within 180 calendar days of the encounter. Electronic signatures or EMR authentication dated
greater than 180 calendar days must include a valid CMS-Generated Attestation for the review to continue.
• In addition:
◦
For physician/practitioner office and hospital outpatient visits: Hospitals often release copies of dictated reports prior to obtaining a
consultant’s signature. These reports then are filed in another physician/practitioner’s record in an “acceptable” form. Diagnoses from these reports
will be coded and abstracted from a physician/practitioner record when either of the following conditions applies: 1) the physician/practitioner has
referenced the report diagnosis as part of his/her documentation in the office record; or 2) the consultation to which the physician/practitioner is
referring is signed and valid as a stand-alone encounter in the data collection period. If the corresponding medical record has a missing or illegible
physician/practitioner signature and/or credential, the MA Organization may wish to consider using the CMS-
Generated Attestation provided in the
CDAT Enrollee Data Package.
◦
For hospital inpatient discharges: For hospital records or records from any risk adjustment-covered inpatient facility, a typed signature alone is
not acceptable. All records must be signed and authenticated by the treating physician/practitioner. Within a lengthy inpatient record, there may be
a few unsigned progress notes or unsigned consultation reports. In this case, the inpatient medical record must contain sufficient signed
documentation to validate any of the audited CMS-HCC(s). The coder will review only the signed documentation when coding the principal and
secondary diagnoses for the enrollee’s discharge; since each provider is required to authenticate their own entries, in most cases unsigned
documentation will not be used for coding. MA Organizations must determine on a case-by-case basis if a record suffices to substantiate the CMS-
HCC being validated.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
17
Table 3: Signature and Credential Issues
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
No Signature
(or Initials)
The MA Organization submits an
inpatient, physician office, or a hospital
outpatient visit medical record.
Inpatient – entire document unsigned:
No physician/practitioner authentication is
on any of the submitted documents for
which relevant conditions are identified.
Inpatient – parts unsigned:
Unsigned documents within acceptable
Inpatient record.
Inpatient:
Submit conditions from only signed
documents. Note that documents may
continue to another page or several pages
where a valid signature is located.
Outpatient:
Request a CMS attestation.
Multiple handwritten encounters in the
same handwriting, on the same page will
be reviewed and, therefore, should be
submitted if one of the encounters is
signed even if the date is different from
the coversheet date.
INV2 – Invalid or lack of signature
Notes on the same page (or sections, such
as continuous progress notes) that are
signed in the same handwriting will be
evaluated on a case-by-case basis to
determine if provider authentication
occurred.
No Signature
(or Initials)
Outpatient/physician:
The selected visit note is not signed or
initialed by a valid physician/practitioner.
Transcribed Reports – Dictated reports
either standard or through voice
recognition software, must be signed by
the physician/practitioner (either
handwritten or with acceptable electronic
signature). The physician/practitioner’s
typed name with transcriptionist’s
identification only is not acceptable.
INV2 – Invalid or lack of signature
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
18
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Electronic
Signatures
Medical record has an electronic signature with
the physician/
practitioner’s discipline indicated within the
record. [See list of Acceptable Physician
Specialty Types (Attachments B1 and B2)].
Acceptable Electronic Signatures:
Accepted by – Acknowledged by – Approved
by– Authenticated by – Charted by – C
losed by
– Completed by – Confirmed by – Created by –
Digitally signed by – Electronically authored
by – Electronically signed by – Entered by –
Entered data sealed by – Finalized by –
Generated by – Read by – Released by –
Reviewed by – Sealed by – – signature on file
{date/time signed} – Signed by – Validated by
– Verified by – Written by – Performed by
(when meaning the exam and related
documentation are being performed by the
same physician/practitioner).
Note that this example would apply also to
notes specified as dictated using Voice
Recognition software with associated
“signature” by an acceptable
physician/practitioner. If there is any question
if the voice recognition document does not
appear properly edited and reviewed by the
dictator, escalate for another opinion.
There is no standard format for
electronic signatures. This guidance is
intended for dictated reports that
require a separate review and dated
signature/authentication. The date
signed should be within 180 days.
Exceptions to the 180 days guidance will
be evaluated on a case-by-case basis for
those signed within the data collection
year and not as a response to the audit
request.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
19
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Unacceptable
Electronic
Signatures
Electronic signatures are an acceptable
form of authentication, but there are
exceptions.
Unacceptable Electronic Signatures:
• Administratively signed by
• Dictated, but not signed
• Electronic signature on file [with no
other indication of a date/time]
• Electronically signed to expedite
delivery
• Proxy signature-Signed via approval
letter or statement, such as:
◦
I authorize my name to be
electronically affixed by using my
unique dictation computer key
◦
Signature on File or Manually
Signed by (The meaning of this is
unknown. In some
transcription/EMR systems, this
might be acceptable but is seems to
mean the physician/practitioner
will hand sign the document after
review.)
EMR formats are not standardized, and the
industry is changing rapidly. Both the
acceptable and unacceptable lists are not
exhaustive.
Request a CMS attestation for
unacceptable electronic signatures.
If the RADV reviewer notes the HCC is
only documented on an unsigned page of
the EMR, the case will be evaluated on a
case-by-case basis.
Reviewer will refer new electronic
signature formats to supervisor for
evaluation on a case-by-case basis to
determine if provider authentication
occurred.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
20
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Point of Service
EMR
Many physician/practitioners are now
using “bedside” EMRs whereby upon
physician/practitioner login, the entry date,
time, and writer are electronically stamped
at the beginning of the note. A final
authentication at the end of the encounter
is not always programmed into the specific
EMR software.
Electronic point of service type medical
record entries are typically considered
authenticated at login since the
physician/practitioner is directly entering
the content into a template and populating
from other sections of the EMR. Often
only the name will be documented at the
beginning or end of the note without the
“electronically signed by” dated notation.
Since EMR formats differ, the presence
and significance to RADV of a signature
authentication statement and a date in a
signature line depends on the structure of
the EMR.
In some cases, the record submitted is a
point of service (POS) type EMR but also
has an electronic signature notation by
either the physician/practitioner or some
other person responding to the audit
request. The late dated or secondary
signature does not make the original POS
entry invalid.
Incomplete
Electronic
Signature
Transcribed reports followed by the phrase
“electronically signed by” or “signed
before import” where there is no
physician/practitioner name are not valid.
The phrase “electronically signed, but not
authenticated,” “signed but not
read/reviewed,” or “electronically signed
but not verified” indicates the
physician/practitioner has not reviewed and
signed off on the electronic version of the
document.
Request a CMS attestation.
RADV reviewer will code the unsigned
physician/practitioner record portions
covered by the valid CMS-Generated
Attestation.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
21
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Likewise, “auto-authorization” EMR
signature programs that add a signature
after a specified number of days are not
acceptable.
Other Signature
Verification
Documents
No signature and/or credentials with,
signature log, business card, blank
prescription pad sheet, or other document
not considered part of the patient medical
record.
Unrequested documentation submitted as a
means to verify the physician/practitioner’s
signature and credential will not be
accepted for review. These methods of
verification were likely introduced into the
medical record solely for the purposes of
validation and not at the time of the
encounter.
Signature logs that are part of inpatient
record documentation procedures are
recorded at the time of the encounter and
are, therefore, acceptable as
signature/credential verification.
Request a CMS attestation.
Cases with any unusual signature logs will
be researched on a case-by-case basis if
there is no valid CMS-Generated
Attestation.
Code only the unsigned record portions
that are covered by the valid CMS-
Generated Attestation.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
22
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Consultation
Reports
Inpatient:
Consultation report submitted without
signature, as part of an authenticated
inpatient provider type medical record
(consultation report is not submitted as
stand-alone documentation). The full
inpatient record may be valid for signature,
but individual reports within the inpatient
record need to be evaluated on a case-by-
case basis for valid authentication prior to
coding.
Outpatient:
The document submitted is a typed (usually
dictated) consultation report only. The
report may be on the consultant’s or
hospital’s letterhead. The report has the
consultants name typed at the conclusion.
The submitted report does not have a valid
electronic or handwritten signature.
The consultation report within the
inpatient medical record is a typed
(usually dictated) report detailing
evaluation of a condition and included at
the request of the attending physician.
There is typically an associated progress
note signed by the consultant on the date of
the patient evaluation.
The attending physician generally will
refer to the consultant’s diagnosis in
subsequent progress notes and his/her final
summary. There may be instances where
disagreement or further work up eliminates
the consultant’s diagnosis from
consideration. As in all medical record
documents, the consultation report is
expected to be authenticated by the
consultant; however, the absence of a
consultant’s signature does not preclude
the attending physician from including the
consultant’s findings in his/her final
diagnosis.
Unless the attending physician explicitly
disagrees with the consultant’s findings,
the documented condition should be
submitted for RADV.
If the final assessment by the specialist
consultant includes an unconfirmed
diagnosis statement (rule-out, suspected,
likely, etc.) impacting the audited CMS-
HCC, and the diagnosis or any related
diagnosis is not eliminated elsewhere in
the record yet not mentioned in the final
discharge diagnoses, a decision will be
made on a case-by-case basis, in
accordance with ICD-9-CM Official
Guidelines for Coding and Reporting.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
23
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Office Note
Referencing
Unsigned Dictated
Report
Coder Guidance: Hospitals/Specialists
often release copies of dictated reports prior
to obtaining the dictator’s signature. These
reports then are filed in another physician's
record in an “acceptable” form.
A signed physician’s note, including a
statement such as “see discharge summary
from <date> hospitalization” or “see
specialist consultation report <date>,”
would be sufficient to link the current
visit/progress note to the dictated summary
without having to re-write all of the
findings.
The circumstances of the current encounter
would determine which diagnoses from the
hospitalization or other visit are still
applicable (i.e., acute, chronic, or status
post).
The entire record is reviewed to
determine the context of any conditions
listed as status post to determine the
correct coding.
Signature Stamp
Acceptable physician authentication
comes in the form of handwritten
signatures and electronic signatures.
Stamped signatures as the only
authentication on a document, are not
acceptable.
Effective April 28, 2008, signature stamps
will no longer be permitted. Source:
Medicare Program Integrity Manual,
Publication 100-8, chapter 3, section
3.4.2.1, CR 5971, Transmittal 248.
Request a CMS attestation.
RADV reviewer will code the unsigned,
stamped record portions only if covered by
the valid CMS-Generated Attestation.
If the signature looks like a stamp but
could also be a digital signature, a
decision will be made on a case-by-case
basis to determine if provider
authentication occurred.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
24
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Signature Location
Beginning of note: It is unusual for a
physician/practitioner to sign a medical
record entry at the beginning of a
transcribed or handwritten note.
Traditionally the signature follows the
medical record entry, but there could be
circumstances where the signature is in an
unusual place and the evaluator can relate it
to the encounter.
Confirm the signature relates to the
encounter that documents the condition
and not a prior encounter. Request a
CMS attestation if not clear.
RADV reviewers will only code the
unsigned record portions that are covered
by the valid CMS-Generated Attestation.
In the unusual instance of an electronic
signature statement inserted into a
handwritten document, it shall be regarded
as equivalent to a “signature on file”
statement, which is not acceptable. These
will be evaluated on a case-by- case basis
to determine if provider authentication
occurred.
Physician Initials
The MA Organization submits a dated
handwritten or typed (non-electronic)
physician office or a hospital outpatient
medical record for the enrollee, and the
selected medical note is initialed by hand.
The physician/practitioner’s name and
credentials appear in the heading. It is
obvious the initials are not those of the
treating physician.
Do not confuse a provider’s initials with
other office staff initialing orders
completed or receipt of a record copy.
Illegible initials are difficult to attribute to
a provider. Request a CMS attestation.
It is common for non-clinical (clerical)
employees to initial records upon receipt
or that the record has been coded. In
addition, there may be clinical staff
members not from an acceptable physician
specialty that have initialed the record. In
this scenario, the medical record would be
deemed invalid.
Code only the unsigned record portions
that are covered by the valid CMS-
Generated Attestation.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
25
What the
Reviewer May
Encounter
Explanation/Example Reviewer Guidance RADV Auditor Action
Illegible Signature
without Legible
Credential
The MA Organization submits a medical
record with illegible physician/practitioner
credentials and no CMS attestation. The
type of physician/practitioner specialty is
not apparent (i.e., no form heading, office
letterhead, or title included in the signature
line). It is questionable whether the face to
face encounter was conducted by a valid
risk adjustment physician data source.
Although a signature may appear illegible,
(squiggles, etc.), if it is located in an
appropriate section of the medical record, it
will be evaluated on a case-by-case basis
since each form and authentication areas are
designed differently.
The term “provider” on a signature line or
form heading is not sufficient to infer one
of the acceptable physician specialties.
MA Organizations should re-request the
medical record legibly identify the
provider. Include another CMS attestation
with instructions.
INV7 – Lack of credential
Code all reportable diagnoses from
illegibly signed physician/practitioner
documents covered by a CMS attestation.
Other Credentials
Often the credential acronym is difficult
to match with one on the acceptable
Physician Specialty list and requires
additional research.
LPC – licensed professional counselor. Do
not assume this is a psychologist or a
LCSW. Not valid for review.
PhD – acceptable when the note is a
mental health encounter. In counseling
notes, the PhD is likely a Psychologist.
Resident, Post Graduate Medical Students
(PGY-1, PGY-2), Hospitalists – Assume
each of these titles implies a Medical
Doctor (MD) or Doctor of Osteopathy
(DO). Valid for review.
Unusual credentials will be researched,
and a decision made on a case-by-case
basis.
MSN, RN – Unless there are further
credentials after research indicating
Nurse Practitioner or other Clinical
Nurse Specialist, this is invalid.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
26
Instructions Received by the MA Organization
Excerpt from CY 2013 Contract-Level RADV CMS Submission Instructions (Chapter 3, Section 2)
All medical records that are submitted must display a clear date of service and be signed by a physician/practitioner with a risk adjustment-eligible
physician specialty. Sometimes a medical record may contain the necessary diagnosis information to validate the audited CMS-HCC(s) but be missing
the signature or credential from the treating physician/practitioner. The lack of these elements will result in an error under the CON13 RADV medical
record review process, leading to a discrepancy for the audited CMS-HCC. (See Section 3 of this chapter for information about CMS-Generated
Attestations, which may be submitted with a record to correct certain deficiencies; note that Attestations are for Physician and Hospital Outpatient
records only, however.)
Dates of Service
• Medical records submitted for this RADV must have a clear date of service within the data collection period. Once again, a medical record submitted
for CON13 RADV need not match the date of service previously submitted to the Risk Adjustment Processing System (RAPS) for the audited CMS-
HCC.
• If a medical record is missing a date of service, then that medical record will be deemed invalid, resulting in an error under the CON13 RADV
medical record review process.
• If the date of service (Physician/Specialist/Hospital Outpatient/Observation record) or admission date to discharge date (Hospital Inpatient record)
on the submitted medical record does not match the designation made by the MA Organization on the Medical Record Coversheet, the medical
record may be deemed invalid and result in an error determination under the CON13 RADV medical record review process. Examples of invalid
dates: fax date, dictation date, review date, missing year of service, date partially cut off.
• Although medical records with discharge date after 12/31/2012 are not acceptable for submission for CON13 RADV, you have the option to submit
any physician encounters that occurred during an inpatient visit with discharge date in the range 1/1/2012–12/31/2012 separately as physician
records. Accordingly, documentation such as the admit note, history and physical, consultations, operative reports, or progress notes that (a) validate
the audited CMS-HCC, (b) meet risk adjustment criteria for signature/credential, (c) are clearly dated in the range 1/1/2012– 12/31/2012, and (d) are
from an acceptable provider specialty may be submitted each with a corresponding Medical Record Coversheet for one Physician or Hospital
Outpatient date of service, up to the maximum number of medical records allowed.
• If a chart note has multiple dates of service on the same page, your MA Organization must complete a separate Medical Record Coversheet in
CDAT for each medical record (i.e., each single date of service) submitted in support of the audited CMS-HCC(s). If only one medical record (i.e.,
one date of service) is being submitted, you should still submit the whole page; coders will review the one date of service indicated on the Medical
Record Coversheet.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
27
Table 4: Date Issues
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance RADV Auditor Action
Undated Visit
Signature Date
Lack of Discharge
Date
Outpatient/physician: The MA Organization
submits a physician office or a hospital
outpatient medical record, and the selected
medical record is not dated.
The only date on the medical record is a
signature date. There is no separate indication of
the encounter date. Inpatient records must have
both admission and discharge date.
Do not submit medical records that do
not support a date of service within the
data collection period.
Depending on the document format, if the
only date on the record is a signature date,
it is not assumed to be the date of service.
The inpatient dates of service must be
documented at least one place in the
record (face sheet, summary, discharge
orders etc.).
INV4 – Invalid for date of service
Evaluated on a case-by-case basis
if admission date is in December
and content may indicate a
discharge not in 2013 for CON14.
An exception may be applicable on a
case-by-case basis when a discharge
or transfer summary contains the
admission date but lacks the
discharge date.
Dictation Date
The medical record submitted is a transcribed
consultation report or discharge summary. The
report does not indicate the date of
consultation, admission date, or discharge
visit. The report has only the dictation date,
and the dictation date is within the data
collection period.
Dictated consultation/medical record with
dictation date and other supporting
documentation:
It is not acceptable to submit conditions
from documents with date of dictation
only.
Submit the document(s) for the DOS
indicated including results data for
pre/post visit testing ordered/ performed
on that date.
INV4 – Invalid for date of
service When there are other
documents to
possibly support the date of service,
these
will be evaluated on a case-by-case
basis. This advice is intended for
orders/testing and follow-up closely
linked, not months apart or occurring
in a different data collection year.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
28
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance RADV Auditor Action
• The medical record submitted is a
transcribed consultation report. The report
does not indicate the date of service. The
report has the dictation date, and the
dictation date is within the data collection
period; AND
• The MA Organization has submitted a
diagnostic service report that is dated for a
service that is referenced in the typed
undated report and matches the Coversheet
date of service (DOS).
BOTH CONDITIONS MUST BE MET.
Dates of Service
outside Data
Collection Period
Inpatient: The inpatient documentation
submitted contains an admission date (within
the data collection period) and a discharge date
(outside the data collection period). Example:
The History and Physical dated in the data
collection year 2013, submitted as a physician
record, though IP discharge date is in 2014.
For inpatient records, the discharge date must
be within the audit’s data collection period. The
admission (from) date may be in a prior year.
Do not submit records with a discharge
date outside the data collection period as
an inpatient provider type. Locate any
physician portions documenting the CMS-
HCC within the data collection period and
submit separate coversheets for each.
INV14 – Invalid for date not within
data collection period
In the case of an admission date in
the prior year, but discharge in the
current data year, the entire
inpatient record is reviewed as one
encounter.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
29
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance RADV Auditor Action
Outpatient & Physician: For physician and
hospital outpatient records, the date of service
must be within the audit’s data collection
period. Example: A discharge summary dated
1/3/2014, which is outside the data collection
year 2013, submitted as a physician record is
invalid.
Date Located on
Encounter Label
An addressograph type stamp or other
electronic demographic identification typically
notes the patient’s name, birth date, patient
number, physician, and admission date. In
ambulatory surgery, the date may be a
registration date prior to the surgery date.
The label date may be interpreted as the
date of service for ED records or other
hospital outpatient single date records.
For ambulatory surgery, use the surgery
date. Include any pre-operative reports.
The reviewer will confirm the date on
the label is consistent with the content
entries.
Ambulatory surgery pre-op history
and physical and testing may note a
prior date but are included in the
review of the surgery record.
Referral Responses
The document describes an outpatient
consultation in response to a referral from
another provider. The medical record may be
in a letter format to the requesting provider or
handwritten on a referral form.
Enter the date of service of the encounter
on the Coversheet. This date should be
documented at the beginning of the
referral response and may be different than
the date of the letter or date of request for
referral.
The content of the document will be
reviewed to determine if it is a
referral response vs. a non-medical
record letter that is not valid for
RADV.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
30
Instructions Received by the MA Organization
Excerpt CY 2013 Contract-Level RADV CMS Submission Instructions (Chapter 3, Section 2)
Inpatient Requirements
• Hospital Inpatient medical records must display an admission date and discharge date and include a signed Discharge Summary (or a Discharge Note
for admissions less than 48 hours).
Physician Specialty and Credentials
• Medical records submitted for RADV must be from an acceptable physician specialty type (see Appendix 3: Reference Materials: CMS- HCCs and
Physician Specialties) and must be authenticated by the provider. MA Organizations must ensure the provider of service for face to face encounters
is appropriately identified on medical records via signature and physician specialty credentials. This means the credentials for the provider must appear
somewhere on the medical record (e.g., next to the physician/practitioner’s signature or pre-printed with the physician/practitioner’s name on the
practice’s stationery). If the credentials of the physician/practitioner are not listed on the stationery, then the credentials must be part of the signature
for that physician/practitioner.
Table 5: Provider Type/Record Issues
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Face to Face Visit
The submitted record documents a face to
face encounter with the enrollee from an
acceptable RADV provider type and data
source. The three acceptable RA provider
types are: Hospital Inpatient, Hospital
Outpatient, and Physician.
Unacceptable physician/practitioner
specialty findings or impressions, such
as diagnostic radiologist, dietitians, or
lab results, must be acknowledged or
referenced in the valid provider’s note
to be submitted for the condition. See
abnormal findings section.
INV 5 – Invalid source, provider type
Inpatient record submissions without a
discharge summary or discharge note
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
31
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Face to Face Visit
(continued)
Note that specific facility sources are not
included as acceptable inpatient and outpatient
facilities; however, acceptable physician provider
type documentation may occur in most any
facility, including the patient home.
The RADV process does not include
determining the type of claim supporting the
original RA data submission. Outpatient and
Physician provider types are combined on the
coversheet, so unless the documentation is
clearly made by an employee from a non-
acceptable source, the coder assumes a physician
provider type based on the acceptable specialty
list.
(for under 48-hour admissions) will
be evaluated on a case-by-case
basis for provider type validity.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
32
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Stand-alone
Discharge Summary
A stand-alone discharge summary is considered
an acceptable physician provider type face to
face visit for the date of discharge or the date of
service documented (if done earlier) as indicated
on the summary and Medical Record
Coversheet.
Inpatient Note: An appropriately detailed
discharge summary that documents at least one
reportable condition and includes the admission
and discharge date with a Medical Record
Coversheet indicating inpatient provider type is
acceptable for review as an inpatient record. An
exception for the lack of or noting a different
discharge date may be granted by the QA
Panel/CMS if the content indicates the actual
date was likely within the data collection year.
Report the conditions documented in
the stand- alone discharge summary
(submitted as IP or OP) keeping in
mind any procedures done during the
admission (i.e., amputations,
ostomies, acute dialysis) are not
reported as a “status” V code.
Review the content carefully to
determine if conditions listed as “status
post” (i.e., MI, CVA) were acutely
active during the current admission or
an earlier one.
Submission of an inpatient record
lacking a discharge summary that does
not appear to contain sufficient
documentation for coding will be
handled on a case-by- case basis.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
33
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Non-face to face
Visit
Although RA submission requires a face to face
visit (with the exception of pathology), RADV
outpatient/physician medical records may
include interpretations of diagnostic tests or
related interventional, minimally invasive
procedures that
do not involve a face to face visit
with the interpreting physician specialist. Even if
the services are not acceptable to submit
diagnoses for risk adjustment (e.g., non-hospital-
based outpatient services), RADV allows the
interpreted reports to support CMS-HCCs in the
data year when interpreted by valid RA provider
specialties.
As in all coding, the Official Guidelines for
Coding and Reporting must be applied. For
inpatient provider type, do not report abnormal
findings of diagnostic results unless the
physician/practitioner indicates the clinical
significance.
Do not submit records that do not
support a face to face visit.
INV 5 – Invalid source, non-face to
face.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
34
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Diagnostic Testing
(with or without
interventional
procedures) with
acceptable provider
interpretation
Acceptable Examples include:
• Cardiology and Vascular Surgeons
◦
Echocardiogram (including Doppler,
Duplex, Color flow of the heart
vessels)
◦
EKG (electrocardiogram) – Stress
test, Cardiac catheterization
◦
Myocardial perfusion and other
nuclear medicine imaging of the
heart
◦
Pacemaker analysis (non-telephonic)
◦
Vascular Doppler Study interpretation-
not performed by Diagnostic
Radiologists
◦
Percutaneous transluminal
coronary angiography (PTCA)
• Interventional Radiology
◦
Catheter angiography – Coronary
Computed tomography angiography
(CTA)
◦
Endoscopic retrograde
cholangio- pancreatography
(ERCP)
◦
Embolization procedures
◦
Extracorporeal shock wave
lithotripsy (ESWL)
Reviewers should only submit
diagnoses documented in the
physician interpretation, not the
technical report.
Do not submit records of
diagnostic radiologist only.
Standalone/outpatient/physician
encounters:
If an exact diagnosis is not reported,
and the record is identified as
outpatient, apply outpatient coding
guidelines to code the condition to the
level of certainty documented. Often
the reason for the test is listed as
symptom or abnormal findings on
another test.
If the reason for the test is to rule out a
diagnosis, do not report the diagnosis if
the exam is normal or does not indicate
the rule out diagnosis.
The reviewer must use judgment based
on the type of procedure/test or other
documentation available when
determining if a chief complaint or
reason for a test is a current diagnosis
or was a condition to be ruled out.
Example: MRA, reason for test: non-
Researched on a case-by-case basis to
determine if study is performed by a
Diagnostic Radiologist or a valid
physician specialist, such as Vascular
Surgeon or Cardiologist.
Stand
- alone/outpatient EKG
interpret
ations are considered for
reporting on a case
- by-case basis. The
cardiologist signature must be present
and
the results supported in the clinical
notes. Findings are often “suggestive of”
and not confirmed diagnoses. This is
especially true for “Old MI (m
yocardial
Infarction)” findings since false positive
findings are not uncommon.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
35
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Diagnostic Testing
(with or without
interventional
procedures) with
acceptable provider
interpretation
(continued)
◦
Magnetic resonance arteriogram (MRA)
◦
Fluoroscopic Guidance
◦
Genitourinary vascular flow
imaging (nuclear medicine)
◦
Radiofrequency ablation
◦
Radiation Therapy – Ultrasound
Guidance Catheter angiography –
Coronary Computed tomography
angiography (CTA)
◦
Endoscopic retrograde
cholangio- pancreatography
(ERCP)
◦
Embolization procedures
◦
Extracorporeal shock wave
lithotripsy (ESWL)
◦
Magnetic resonance arteriogram (MRA)
◦
Fluoroscopic Guidance
◦
Genitourinary vascular flow
imaging (nuclear medicine)
◦
Radiofrequency ablation
◦
Radiation Therapy – Ultrasound
• Neurology
◦
Electroencephalography (EEG)
◦
Electromyography (EMG)
◦
Nerve Conduction Studies
healing ulcer. MRA studies rule out
vascular or heart disease, not ulcers.
The ulcer would be reported as a
current condition along with any
abnormal findings of the study.
Interpreted diagnostic testing
within inpatient records:
See guidance for Other Physician
Documentation. Generally,
interpretations from acceptable
provider specialties are acceptable as
long as there is no contradiction with
the attending physician diagnosis.
Diagnoses documented in EKGs,
MRA, Doppler studies, and other
testing must be addressed by the
attending physician or consulting
provider to submit for condition
validation.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
36
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Diagnostic Testing
(with or without
interventional
procedures) with
acceptable provider
interpretation
(continued)
◦
Nuclear Medicine Brain imaging
◦
Sleep Studies (Polysomnography)
• Pulmonology
◦
Pulmonary Function Tests (PFT)
◦
Pulmonary perfusion and ventilation
imaging
Technical
Component Only
Diagnostic testing and infusion type encounters
are generally performed by technical staff not
included on the list of acceptable physician
specialties. If there is no accompanying
interpretation or consultation by a physician
specialist, other than diagnostic radiology, the
provider type is invalid for RADV. Examples:
pacemaker analysis, INR (International
normalized ratio) blood coagulation (clotting)
checks.
Do not submit studies only
documented by non- physician
technicians or nurses.
INV5 – Invalid source
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
37
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Clinical Laboratory
Test Results
(e.g., “blood test”
results, urinalysis
results, etc.)
submitted as stand-
alone medical record
Clinical lab test results, when submitted alone,
are not acceptable for RADV purposes. If the
only medical record documentation submitted is
a clinical lab report, the medical record is
considered “Invalid.” Examples of the types of
documentation that are unacceptable, when
submitted alone, include the following:
• CBC blood count report; Chemistry
profile report
• Hepatitis antigen/antibody tests
• Pleural fluid analysis report
• Rheumatoid factor
• Urinalysis report, Urine culture report
• Urine pregnancy test
• Wound culture report
NOTE: The above list is not all inclusive.
Do not submit lab results to
validate conditions. Request the
office visit where the results were
ordered, or the results were
reviewed with the patient.
INV5 – Invalid source
Pathology Reports-
with pathologist
interpretation
(including surgical
pathology,
cytopathology, etc.)
with an interpretation
by a pathologist
The interpretation of the findings by a
pathologist as an acceptable physician specialty
is acceptable. This is an exception to the face to
face requirement.
Examples of pathology reports include
the following:
• Pathology report from a tissue biopsy
(e.g., lung biopsy, bone biopsy, etc.)
• Cell block report
Enter date of collection as the date of
service. The interpretation and findings
may be submitted to validate
conditions.
Locate “collection date” or “results
date” to match with DOS being
reviewed. Either is acceptable.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
38
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Pathology Reports-
with pathologist
interpretation
(including surgical
pathology,
cytopathology, etc.)
with an interpretation
by a pathologist
(continued)
• Cytopathology report of fluids/brushings
• PAP (Papanicolaou) smear report
• Chromosome analysis
Pathology Reports-
laboratory test only
(including surgical
pathology,
cytopathology, etc.)
without an
interpretation by a
pathologist
Pathology reports, when submitted as a
laboratory test alone, are not acceptable for risk
adjustment purposes.
Do not submit lab results to
validate conditions. Request the
office visit where the results were
ordered, or where the results were
reviewed with the patient.
INV5 – Invalid source
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
39
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Telephone or
Telemedicine/Video
Contact
The MA Organization submits a medical
record, and the selected visit note is
documentation of a telephone/video contact
with the enrollee or is documentation of lab
values received over the telephone.
Medicare policies for telemedicine apply. The
medical record of the origin site must include
documentation by a valid risk adjustment
provider specialty. The remote consultation
report should
be mentioned and included in that origin
site encounter record.
Video chat type encounters that are not face to
face with a valid risk adjustment provider are
not valid.
Telephone encounters are not valid.
Do not submit documentation of
telephone contacts to validate
conditions. Telemedicine
documentation is allowable in only
limited situations.
INV5 – Invalid source
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
40
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Emergency
Department (ED)
The MA Organization submits a medical record
for an ED visit. ED records often consist of
multiple check-off sheets from various members
of the treatment team with signatures not always
on the same page as the documentation.
The ED record date of service is considered part
of the inpatient date range when followed by a
direct admission.
Review all pages of the ED record
whether dated or not. MA
Organizations should report only
conditions either documented by or
clearly reviewed and signed off by an
acceptable RA physician/practitioner
specialty.
Conditions ruled out during the ED
testing or conflicting with the
Emergency Room (ER)
physician/practitioner’s (i.e., MD,
Physician Assistant [PA], Nurse
Practitioner [NP]) final note should
not be submitted.
Only submit diagnoses from the ER
records not overturned by IP
documentation.
If from date is next day after ED date,
date may pass validity.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
41
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Observation Visits
Observation “admissions” are typically under
24 hours. Longer observations are possible, and
in those cases, the MA Organization is
instructed to enter the first date of observation
status as the DOS on the coversheet and
reflected in CDAT. Any of the observation
dates selected at intake for review within the
data collection period are acceptable.
Observation encounters submitted as IP
provider type on the face sheet.
Confirm the observation status was
clearly documented and not later
changed to inpatient. Check the face
sheet patient status, orders, ED
disposition, and final progress notes
for documentation or mention of
Observation Status, 24-hour hold, or
similar terminology.
Submit the observation encounter as
an outpatient for any conditions
documented within the entire
observation stay.
INV15 – Invalid provider type if
observation is submitted as an
inpatient
If status is inconsistently documented
in the record resulting in a discrepancy
in provider type, the
decision will be handled on a case-by-
case basis. The RADV reviewer will
code from the entire observation range
of dates.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
42
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Problem Lists
(within a medical
record)
See related topic of Chronic and Other
Additional Diagnoses. Lists of diagnoses
(conditions, problems) may be numbered,
bulleted, or separated by commas. A list may be
documented in the patient history, assessment,
discharge summary, or other areas of a medical
record. When conditions commonly associated
are listed under the same number or bullet, the
conditions can assume to be linked. These
diabetes examples are effective for ICD-9-CM
and will be updated for ICD-10-CM.
Example 1:
1. Hypertension
2. DM, neuropathy
(link diabetes and neuropathy)
Example 2:
1. Hypertension
2. DM
3. Neuropathy
(do not link diabetes and neuropathy)
Evaluate the problem list for evidence
of whether the conditions are chronic
or past and if they are consistent with
the current encounter documentation
(i.e., have they been changed or
replaced by a related condition with
different specificity). Evaluate
conditions listed for chronicity and
support in the full medical record,
such as history, medications, and final
assessment. Do not submit conditions
from lists labeled as PERTINENT
NEGATIVES.
Problem lists are evaluated on a case-
by-case basis when the problem list is
not clearly dated as part of the face to
face encounter indicated on the
coversheet or there are multiple dates of
conditions both before and after the
DOS.
Lists of conditions written by the
patient are not acceptable.
Lists of code numbers without
narratives are not acceptable.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
43
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Problem Lists
(within a medical
record)
(continued)
Example 3:
1. Diabetes with hypertension
(Although these conditions could occur together
and be related, unless the documentation clearly
shows a cause and effect relationship,
do not link
diabetes and other condition if not typically a
known manifestation of diabetes.)
Mention of EMR population of
diagnoses in a list will be considered on
a case-by-case basis for RADV once all
other coding rules and checks for
consistency have been applied.
Skilled Nursing
Facility (SNF)
The MA Organization submits a SNF record as
an inpatient provider type.
SNF record with no physician specialty
encounter documentation.
Example: Nursing Home case management
conference summaries.
The submission is a
physician/practitioner visit
that indicates the enrollee is a resident of the
SNF. Although CMS does not accept risk
adjustment data from nursing home facilities (as
an inpatient provider type), some beneficiaries
who reside in a nursing home will ha
ve a nursing
home medical record (single acceptable
physician specialty encounter) as the only source
to support their diagnostic data.
The physician/practitioner’s encounter must
have been face to face with the beneficiary.
Do not submit SNF records as an
inpatient provider type. Do not submit
portions or SNF records unless the
encounter is documented by a valid RA
specialty.
Locate physician note for DOS.
Often MD visit documentation is
part of the orders template.
Review progress notes for Physical
Therapists or other types of acceptable
outpatient therapists that may support
the condition and could be submitted
separately as an OP encounter.
INV5 – Invalid for inpatient provider
type RA source
Notes are reviewed for documentation
of a separate valid provider, not an
employee of the SNF.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
44
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Health Risk
Assessments
(HRAs)
HRA forms must be completed by a valid risk
adjustment provider specialty. Those completed
by the patient are not acceptable. The
documentation must support that the provider
was present with the patient. Conditions listed
are evaluated for chronicity and support in the
full medical record, such as history,
medications, and final assessment. Results of
HRA screening portions are not considered
confirmed diagnoses unless supported by the
final assessment documentation.
Do not submit HRA forms that do not
document a face to face encounter. The
provider documentation of dated
patient vitals is one element that
supports a face to face encounter.
HRA forms that do not appear to be a
face to face encounter will be evaluated
on a case-by-case basis.
Since the HRA is primarily a
question and answer form that can be
created online or over the phone, the
physician signature is not always
sufficient to validate the provider
was present.
Referral
Authorization
Forms
The MA Organization submits a signed and
dated referral authorization form (not
documenting a face to face encounter).
Do not submit conditions documented
only on referral authorization forms.
Request instead the office visit/consult
in which the patient was evaluated.
INV5 – Invalid source
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
45
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Order Forms
Documenting an
Encounter
The MA Organization submits a signed and
dated order form with evidence of a face to face
encounter. Order forms often have as much
clinical information as a progress note or are
used as a combined progress note and order.
Examples:
1. Inpatient order sheet stating date of service,
diagnosis, and treatment submitted with
other confirmed inpatient documentation.
2. Inpatient order sheet submitted as a stand-
alone physician provider type for one date
of service.
3. Outpatient or physician order form (often on a
prescription pad form) stating date of encounter,
diagnosis, and treatment ordered.
Submit conditions only to the level
confirmed in the documentation. The
reason for the test may be to rule out
a condition not yet diagnosed.
Do not use prescription drug
information on the order form to report
conditions. The condition must be
documented.
These will be evaluated on a case- by-
case basis. Not all order forms are valid
for review.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
46
What the Reviewer
May Encounter
Explanation/Examples Reviewer Guidance RADV Auditor Action
Prescription Forms
For drugs that do not contain a diagnosis or
other evidence of a face to face visit:
The MA Organization submits a signed and
dated prescription form ordering a diabetic
medication or other condition-specific
medication.
Prescription forms for drugs that do contain a
diagnosis or other evidence of a face to face
visit:
Outpatient or physician order form (often on a
prescription pad form) stating date of encounter,
diagnosis, and treatment ordered.
CMS does not accept prescriptions as a form
of validation.
Prescription forms documenting only a drug
order are not acceptable as a stand-alone
document, even if the drug named is used only
for one condition.
Review carefully that a separate face to face
encounter is clearly identified.
INV5 – Invalid source
Evaluated on a case- by-case
basis.
Certified Clinical
Nurse Specialist
The MA Organization submits medical record
documentation signed and dated by a Certified
Clinical Nurse Specialist (CNS), Advanced
Practice Registered Nurse (APRN), APR-CNS,
or Psych CNS.
For RADV, the approved specialties of Certified
Clinical Nurse Specialist, Nurse Practitioner,
Certified Nurse Midwife, and Certified
Registered Nurse Anesthetist all fall in the
sometimes-used blanket designation of
Advanced Practice Registered Nurse (APRN,
APN, or APR-CNS), so these credential terms
are also acceptable.
It is acceptable to submit documentation
from nurse practitioners.
MSN-RN without further
specialty noted will be
researched on a case- by-case
basis.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
47
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Therapists
Physical Therapy
(PT)
Occupational Therapy
Speech and Language
Pathology
Clinical Licensed
Social Worker (stand-
alone evaluation and
treatment)
Other Specialties or
Credentials
Outpatient Provider Type:
These therapists are included in the acceptable
physician specialties for RA. Therapy
evaluations typically include the patient’s past
and current conditions, including chronic
conditions not related to the therapy.
Inpatient Provider Type:
Ancillary services are typically provided by
employees of the facility and their findings are
under the responsibility of the attending
physician. Therefore, these services are not
considered separate professional specialists as is
the case in outpatient encounters.
Clinical Research Professionals – CPI. This is a
designation by a physician/practitioner
responsible for clinical trials. The professional
would have another acceptable physician/
practitioner specialty of MD, PA, or other.
Note that Radiologists or other medical
professionals may be performing in the capacity
of a general practitioner for purposes of face to
face HRAs. This is acceptable as long as the
physician/practitioner’s credentials are MD, DO,
PA, or NP.
Submit all reportable diagnoses from all
RADV approved specialty therapy
outpatient/physician submissions.
For inpatient coding, reportable
diagnoses must be documented by the
attending or consulting doctor
specialists. Conditions documented only
in inpatient ancillary service notes
should not be submitted for validation.
Make sure the documentation supports an
acceptable specialty or credential.
When submitted as a stand-
alone outpatient/physician
document, the reviewer may
consider the medical record
submission as valid for review.
Diagnoses documented on the
authenticated therapy document
are valid for coding according to
outpatient coding rules.
If the coder comes across other
credentials or unusual
circumstances of specialists
performing home visits or
HRAs, the case may be
evaluated on a case- by-case
basis.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
48
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Therapists
Physical Therapy
(PT)
Occupational Therapy
Speech and Language
Pathology
Clinical Licensed
Social Worker (stand-
alone evaluation and
treatment)
Other Specialties or
Credentials
(continued)
“Adult Medicine” notes or clinics are generally
staffed by general practice or internal medicine
physician/practitioners (MD, DO, PA, NP) and
notes from these acceptable
physician/practitioners may be reviewed.
Note that the RADV team does not update the
specialty list. We can only provide examples of
credentials on the list until the next CMS RA
policy release.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
49
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Other Unacceptable
Source Documents
Other types of unacceptable medical
record documentation include:
• List of ICD-9-CM codes
• Ambulance
• Claim forms-may possibly be used to verify
dates, credential, or legibility issues but not
for coding purposes
• Claims data pre-populated conditions (case-
by- case basis due to EMR differences)
• Durable medical equipment
• Hospice care in a hospice designated unit
or facility
• Hospital inpatient swing bed components
also called Transitional Care Units
• Home Health Facility agency staff
documentation or certifications (CMS 485
forms) that do not document a face to face
visit with the physician/practitioner. DO
NOT CONFUSE physician provider type
HOME VISITS, HRA done in the home by a
health plan or their contracted service, OR
HOUSE CALLS with HOME HEALTH
AGENCY encounter sources
• Intermediate care facilities
• List or check list of patient conditions
Lists of ICD-9-CM codes with narratives are
acceptable when included as part of a
documented face to face office visit/exam.
These need to be reviewed on a case-by-case
basis and questioned when accompanied by
notation of “pre-populated from claims data”
or similar terminology.
ICD-9-CM codes without narrative are not
acceptable to report in place of a diagnosis to
support a CMS-HCC. It is the codes that are
being validated by medical record written
documentation.
AHA Coding Clinic 1Q 2012 p. 6* states
“Question: Since our facility has converted to
an electronic health record, providers have the
capability to list the ICD-9-CM diagnosis
code instead of a descriptive diagnostic
statement. Is there an official policy or
guideline requiring providers to record a
written diagnosis in lieu of an ICD-9-CM
code number?
(Answer listed in the next row.)
INV5 – Invalid source
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
50
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Other Unacceptable
Source Documents
(continued)
without evidence of a face to face visit (see
also problem list section)
• Orthotics
• Print outs of claim screens
• Prosthetics
• Respite care facilities
Other Unacceptable
Source Documents
(continued)
Other types of unacceptable medical
record documentation include
(continued):
• Super bills
• Supplies
• Repetitive encounter flow sheets without
physician note for the date of treatment (e.g.,
dialysis, infusion/injections, chemotherapy,
radiation, Coumadin/INR/Protime).
Answer: Yes, there are regulatory and
accreditation directives that require providers
to supply documentation to support code
assignment. Providers need the ability to
specifically document the patient's diagnosis,
condition, and/or problem. Therefore, it is
not appropriate for providers to list the
code number or select a code number from
a list of codes in place of a written
diagnostic statement. ICD-9-CM is a
statistical classification, per se; it is not a
diagnosis. Some ICD-9-CM codes include
multiple different clinical diagnoses, and it can
be of clinical importance to convey these
diagnoses specifically in the record.
INV5 – Invalid source
(continued)
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
51
What the
Reviewer May
Encounter
Explanation/Examples Reviewer Guidance
RADV Auditor Action
Other Unacceptable
Source Documents
(continued)
Also, some diagnoses require more than one
ICD-9- CM code to fully convey. It is the
provider's responsibility to provide clear
and legible documentation of a diagnosis,
which is then translated to a code for
external reporting purposes.”
© Copyright 1984-2017, American Hospital
Association ("AHA"), Chicago, Illinois*
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
52
Other Documentation Issues
This section includes other documentation issues involving the support of diagnoses within a valid medical record. Policies may differ depending on the
provider type. Review of the entire medical record, including all terms directly attributed to the condition and who documented the condition, are
important in making these reporting decisions. Conditions, diagnoses, or “problems” can be listed in various sections of a medical record. With an EMR,
conditions from previous encounters are often brought forward/cut and pasted/auto-filled into the current encounter template by various methods. The
question is whether these conditions should be reported for the current encounter and how to interpret “treatment and care” and “affect patient
management” in the Official Guidelines for Coding and Reporting quoted below. Section numbers are indicated after each quote.
Conversely, some conditions are listed as a current condition, but the content of the full record indicates the condition is no longer present. Therefore,
reviewers should evaluate all listed conditions, both chronic and acute or short-term conditions for consistency within the full provider documentation of
the one encounter submitted for RADV. Mention of EMR population of diagnoses in a list will be considered on a case-by-case basis for RADV once all
other coding rules and checks for consistency have been applied.
Chronic and other additional diagnoses
ICD-9-CM Official Guidelines for Coding and Reporting – Outpatient Services
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the conditions(s).
(Section IV, J)
Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management.
(Section IV, K)
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
53
ICD-9-CM Official Guidelines for Coding and Reporting – Inpatient Services
GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES (Section III)
For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:
• clinical evaluation; or
• therapeutic treatment; or
• diagnostic procedures; or
• extended length of hospital stay; or
• increased nursing care and/or monitoring.
The Uniform Hospital Discharge Data Set (UHDDS) item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that
develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing
on the current hospital stay are to be excluded.” UHDDS definitions apply to inpatients in acute care, short-term care, long-term care, and psychiatric
hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. These
data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038–40.
Since the application of the UHDDS, definitions have been expanded to include all non-outpatient settings (acute care, short-term care, long-term
care, and psychiatric hospitals; home health agencies; rehabilitation facilities; nursing homes, etc.).
AHA Coding Clinic for ICD-9-CM © 3rd Qtr, 2007, p. 13–14*
Question:
We need to get clarification on the coding of chronic conditions. One of the quality improvement organizations (QIOs) will not allow the inclusion of
chronic obstructive pulmonary disease (COPD) as a secondary diagnosis when it is only mentioned as a history of COPD and no active treatment is
documented. Am I correct in stating the presence of a documented history of COPD in the physician's history and physical on an inpatient record is
enough to code COPD as a secondary diagnosis since this is a chronic condition that always affects the patient's care and treatment to some extent?
Answer:
As stated in Coding Clinic, July–August 1985, page 10, the criteria for selection of the conditions to be reported as “other diagnoses” include the
severity of the condition, use or consideration of alternative measures in the treatment of the principal diagnosis due to a coexisting condition,
increased nursing care required in the care of patients due to the disabling features of the coexisting condition, use of diagnostic or therapeutic
services for the particular coexisting condition, the need for close monitoring of medications, or modifications of nursing care plans. If there is
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
54
documentation in the medical record to indicate the patient has COPD, it should be coded. Even if this condition is listed only in the history section
with no contradictory information, the condition should be coded. Chronic conditions such as, but not limited to, hypertension, Parkinson's disease,
COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further
evaluation. Some chronic conditions affect the patient for the rest of his or her life and almost always require some form of continuous clinical
evaluation or monitoring during hospitalization, and therefore should be coded. This advice applies to inpatient coding.
The following guidelines are to be applied in designating “other diagnoses” for both inpatient and outpatient when neither the Alphabetic Index nor
the Tabular List in ICD-9-CM provides direction. The listing of the diagnoses in the patient record is the responsibility of the attending
provider.
ICD9-CM Official Guidelines for Coding and Reporting
Underlying Conditions
Conditions that are an integral part of a disease process “Signs and symptoms that are associated routinely with a disease process should not be
assigned as additional codes, unless otherwise instructed by the classification.” (Section I, B. 7)
Conditions that are not an integral part of a disease process “Additional signs and symptoms that may not be associated routinely with a
disease process should be coded when present.” (Section I, B. 8)
Previous Conditions
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, ICD-9-CM personal history codes (codes V10-V19) may be used as secondary codes if the historical condition or family history has an
impact on current care or influences treatment. (Section III, A) [For example, the Official Coding Guidance regarding neoplasms states:
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that
site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm,
should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to
another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the
V10 code used as a secondary. (Section I, C. 2d)]
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
55
Abnormal Findings
Inpatient: 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. (Section III, B)
Outpatient: For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of
coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional
diagnoses. (Section IV, L)
Uncertain Diagnoses
Inpatient: If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be
ruled out,” 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. (Section III, C)
Outpatient: Do not code diagnoses documented as “probably,” “suspected,” “questionable,” “rule out,” “working diagnosis,” or other similar terms
indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal
test results, or other reasons for the visit. (Section IV, I)
AHA Coding Clinic for ICD-9-CM © 1st Qtr, 1999, p. 5*
Question:
A patient comes into the hospital with a fracture of the femur. On discharge, the physician lists in his final diagnostic statement, fracture of femur.
However, when reviewing the medical record, the X-ray report states the site of fracture is the shaft of the femur. Is it appropriate to use the X- ray
results to provide further specificity to this diagnosis for coding purposes?
Answer:
Assign code 821.01, Fracture of other and unspecified parts of femur, Shaft. Coders should always review the entire medical record to ensure complete
and accurate coding. If the physician does not list the specific site of the fracture, but there is an X-ray report in the medical record that does, it is
appropriate for the coder to assign the more specific code without obtaining concurrence from the physician. However, if there is any question as to the
appropriate diagnosis, the coder should consult with the physician before assigning a diagnosis code.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
56
Other Physician Documentation
Medical records often contain documentation from more than one acceptable RA provider specialty. Inpatient records especially require careful
review to determine if conditions documented by providers other than the attending physician are confirmed, relevant, and consistent with the final
diagnoses.
AHA Coding Clinic for ICD-9-CM© 1st Qtr 2004, p. 18*
Question:
Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other
than the attending physician. Previously published Coding Clinic advice has allowed using documentation from the anesthesia report. Our coders
have interpreted the lack of contrary documentation from the attending can be perceived as concurrence with the anesthesiologist. We have recently
been advised we cannot use a consultant’s note without “confirmation” from the attending physician. Our coders tell us it is operationally impossible
to confirm every single diagnosis or condition the consultant writes. Of course, if there is conflicting information, we will query the attending
physician for clarification. Can you comment on whether our interpretation of coding instructions is correct?
Answer:
Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting
information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient,
including documentation by consulting physicians, is appropriate for the basis of code assignment. A physician query is not necessary if a physician
involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis, and there is no conflicting
documentation from another physician. If documentation from different physicians’ conflicts, seek clarification from the attending physician, as he or
she is ultimately responsible for the final diagnosis. This information is consistent with the American Health Information Management Association’s
(AHIMA) documentation guidelines.
*For all AHA Coding Clinic for ICD-9-CM references the following statement applies:
© Copyright 1984–2017, American Hospital Association (“AHA”), Chicago, Illinois. Reproduced with permission for the express purpose of instructions for
responding to this federally mandated audit validating Medicare payment. No portion may be copied without the express, written consent of AHA. Individual
answers within AHA Coding Clinic® are available for reproduction by hospitals and health systems for the purpose of responding to payor audit requests. The
answer needs to be reproduced in its entirety, and not edited or altered in any way. Payors, consultants, and other for-profit, commercial entities may only
use AHA Coding Clinic® content as an internal reference and for audit purposes. AHA Coding Clinic® content may not be utilized for commercial, for-
profit purposes and may not be re-sold, repackaged or distributed without the consent of the American Hospital Association Central Office. The Content may not be
compiled, shared, or distributed in a way that circumvents the need for an individual or entity to access, purchase, or obtain a license to utilize Coding Clinic
content. AHA Coding Clinic is an official resource for Medicare Risk Adjustment coding. Subscription and licensing information can be viewed at
http://www.ahacentraloffice.org/codes/products.shtml#CodingClinic
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
57
Table 6: Documentation Issues
What the
Reviewer May
Encounter
Explanation/Examples
Reviewer Guidance
RADV Auditor Action
No Exam, Reason
for the Encounter,
or Condition
Documented
Coder Guidance: The medical record for the one
visit or admission selected by the MA
Organization does not contain any documentation
of the type of exam or other reason for the visit
(e.g., the record only documents the enrollee’s
vital signs and height and weight).
Do not submit the medical record if
no conditions are documented.
Reviewer will assign applicable V code
if possible or flag as “No ICD-9.”
No Documented
Findings,
Symptoms, or
Conditions
The medical record documentation includes a
type of exam or screening with no positive
findings, symptoms, or conditions. Examples
include:
• Annual check up
• Adult physical exam (APE)
• Blood pressure check
• Cholesterol check
• Prostate Specific Antigen (PSA)
• Therapy session
• Follow-up (F/U) exam
• Pre-op exam
• Well visit
Do not submit the medical record if
no conditions are documented.
Reviewer will assign applicable V code
if possible or flag as “No ICD-9.”
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
58
What the
Reviewer May
Encounter
Explanation/Examples
Reviewer Guidance
RADV Auditor Action
Illegible Diagnosis
– Handwriting
The only diagnoses in the medical record submitted
are illegible due to handwriting.
Some illegible (or non-English or both) words
that are possibly a diagnosis.
Unless there is no other record
available, do not submit medical
records that cannot support the
CMS-HCC due to illegibility.
Be careful of illegible negative
finding (e.g., [No or R/O] CHF)
where the preceding word is illegible.
If, after review of context, similar
words,
medications, etc., the coder is not
able to decipher an illegible word that is
documented in areas typically
containing diagnoses or with other
legible diagnoses, the CMS- HCC to be
validated is checked to determine if that
condition is legible and already
validated on the record or is possibly the
illegible word.
If a second review still indicates the
condition is illegible, it will not be
coded.
Illegible Diagnosis
– Document Image
The only diagnoses in the medical record
submitted are illegible due to a document image
that is too light, too dark, or distorted.
Do not submit the record.
Request a clear copy from the
provider.
Medical record cannot be coded.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
59
What the
Reviewer May
Encounter
Explanation/Examples
Reviewer Guidance
RADV Auditor Action
Non-English
Documentation
Coder Guidance: The record submitted
includes diagnoses, but the words are not
English.
Identify the documentation that
validates the CMS-
HCC. If it is
legible and can be translated, then it is
acceptable to submit.
Refer to Medical Record Review
Contractor (MRRC) Project Manager
regarding resources for medical
translation of pertinent sections of the
medical record.
Abbreviation with
Multiple Meanings
Coder Guidance: Several common
abbreviations have more than one meaning.
Examples: MD – major depression,
muscular dystrophy, macular degeneration
CRF – chronic renal failure, chronic
respiratory failure
Evaluate the abbreviation within the
context of the full medical record
before submitting to support the
condition.
If more than one meaning applies or
documentation is too limited to
differentiate, and this is the only
diagnosis listed within the record,
evaluate on a case- by-case basis.
Otherwise, use discretion to report or not
based on other circumstances in the
record.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
60
What the
Reviewer May
Encounter
Explanation/Examples
Reviewer Guidance
RADV Auditor Action
Medical Record
Amendments
See
detailed definitions in
Appendix C.
An
amendment is an
alteration of the health
information by
modification,
correction, addition,
or deleti
on.
Acceptable Amendment: An amendment must
be based on an observation of the patient on the
date of service and signed by the physician. Only
the attending or treating physician can amend the
medical record. The most common example is for
follow-up notes based on a diagnostic test ordered
and related test results received subsequent to the
patient visit. Sufficient information must be
contained in the amendment to verify the
documentation was completed in a timely manner
by the attending or treating physician. For RADV
"timely manner" generally means up to 90 days
from the encounter but there could be exceptions
such as extended specialized or revised lab/path
results or autopsies, legal cases sequestered before
completing record, natural disasters, or delays due
to physicians called to military service.
Unacceptable Amendment – It is unacceptable
for a third party that was not involved in the
treatment and evaluation of the patient (e.g., coder,
reviewer) to amend the medical record or query the
provider for additional diagnoses or clarifications
not documented in the original medical record.
It is not appropriate to add diagnoses
to the medical record that have been
identified by a source other than the
treating physician (e.g., identifying
diabetes from a disease management
program).
If the unacceptable amendment is
the only source of the CMS-HCC,
select a different record for
submission.
RADV reviewer will code reportable
diagnoses from acceptable amendments.
Reviewers will ignore unacceptable
amendments for coding.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
61
What the
Reviewer May
Encounter
Explanation/Examples
Reviewer Guidance
RADV Auditor Action
Query Forms See
detailed definitions in
Appendix C.
A query
is a communication
tool used to clarify
documentation in the
health record for
accurate
code
assignment. The
desired outcome from
a query is an update of
a health record to
better reflect a
practitioner’s intent
and clinical thought
processes,
documented in a
manner that supports
accurate code
assignment.
When submitted with the associated medical
record, diagnosis query forms that are completed,
signed, and dated in a timely manner (i.e., within
90 days of the date of service) by the
physician/practitioner and became part of the
official medical record will be reviewed for validity
and clinical consistency with the medical record
documentation.
For RADV, a coder or clinical documentation
improvement specialist may query a
physician/provider at the time of the encounter and
the response documented and authenticated by that
physician/provider is what is meant by a medical
record query. The query form letter becomes part of
the official medical record per that facility’s
documentation policies. This is a standard of
practice defined by CMS recognized leaders in
health information documentation, the American
Health Information Management Association
(AHIMA)
Some MAO’s have adopted similar appearing
MAO coder/physician “query” labeled type letters.
Examples of these have been found in prior RADV
audits added as unacceptable alternative data
sources to their RADV submissions to attest to
prior claim HCCs or additional diagnoses after the
original encounter.
Query type forms generated by the
MA Organization or their coding
staff contractors are not acceptable
for review as part of the medical
record. They are considered
extraneous data from an alternative
data source not allowed per Risk
Adjustment policy.
If the unacceptable query type form is
the only source of the HCC, select a
different record for submission.
Query forms will be considered on a
case-by-case basis to determine
whether the document is an acceptable
standard physician query made by a
coder or similar facility staff at or near
the time of the encounter or if it is some
other unacceptable late addition of
conditions after the original encounter.
RADV reviewer will not code from
documents even if labeled (incorrectly)
as “coder query” if the documentation is
not generated at or near the time of the
encounter by the facility or physician
office.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
62
What the
Reviewer May
Encounter
Explanation/Examples
Reviewer Guidance
RADV Auditor Action
The final coded
diagnoses and
procedures derived
from the health record
documentation should
accurately reflect the
patient’s episode of
care. Source: AHIMA
Practice Brief:
Guidelines for
Achieving a
Compliant Query
Practice
.
Missing Pages
In some instances, it is possible to identify
missing pages from a pre-numbered medical
record or a partial record submission.
Example: A History and Physical (H&P) with
pages 1 and 3; however, page 2 is missing.
Example: First line of a document submitted
appears to be a continuation from a previous
page.
Consider re-requesting the full
medical record from the provider.
Reviewer will code from available pages
if the record meets other validity criteria
(signature, credential, etc.). If no
condition is present to code, then it will
be evaluated on a case-by-case basis.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
63
What the
Reviewer May
Encounter
Explanation/Examples
Reviewer Guidance
RADV Auditor Action
Medical Record
Documentation is
Distorted or
Obscured
In some instances, the record documentation is
obscured by sticky notes or other markings on
the document.
Do not submit documents with
obscured portions.
Reviewer will code from legible pages.
Medical Record
Documentation is
Too Dark or Too
Light
Some medical record documentation is of poor
image quality, and the Senior Evaluator (SE)
is unable to identify key elements.
This is common in photographed records.
Check that scanned images are
readable. If needed, re-request the
medical record.
Reviewer will code from legible pages.
Pages or Margins
of the Medical
Record are Cut
Off
Some medical record documentation can have
portions of the record text cut off during the
submission.
Check that scanned images are
readable. If needed, re-request the
medical record.
Reviewer will code from legible pages.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
64
Appendix A: What Makes a Medical Record Invalid for RADV?
During Intake Evaluation, the MRRC SE answers all of the following questions relative to each medical record. Only results from valid medical
records are used for the payment error calculation.
• Question 1 (INV1) = Does the medical record correctly identify the sampled beneficiary? Senior evaluator fails this check if the medical record
name and identifying information is completely different from the name on the Medical Record Coversheet (sampled beneficiary CMS- HCC). If
INV1= NO, SE will evaluate if name is a derivative as in INV3 and change to YES. The SE may escalate this record to request CDAT support to
determine if enrollee is in the sample. See related INV3 and INV 20. If INV3=YES, the system WILL NOT move the record forward for coding
unless the SE changes INV1 to YES also.
• Question 2 (INV2) = Is the medical record signed? The SE fails this check if the medical record submitted is not signed at all. The signature
does not have to be complete or legible. Note: The SE does not answer this based on the presence of an attestation, only the medical record
document.
• Question 3 (INV3) = Is the name on the medical record an acceptable variance of the name of the sampled beneficiary? SE fails this check
when the name on the medical record is similar but does not match the Medical Record Coversheet. The SE may decide the name is acceptable or not
and, if not acceptable, fail both INV3 and INV1. Examples of possible scenarios include reported Health Insurance Claim Number (HICN) is spouse’s
number, use of middle name as first name, maiden name, and father/son mix up with same name but different birth date. The SE may escalate this
record for further clarification or questions. INV3 should never = NO without INV1=NO also. If name was corrected on the coversheet, SE will
assign INV3=YES with a comment describing the difference.
• Question 4 (INV4) = Is there a date on the medical record? Does the medical record contain a valid date of service? The SE fails this check if the
date is missing completely or only partially there and the year cannot be confirmed.
• Question 5 (INV5) = Is the medical record from a valid source? The SE fails this check for invalid sources, which are not on the acceptable
sources list, such as: hospice, home health, lab only, super-bill, and non-face to face. The SE also fails this check if the physician/practitioner
credential/specialty is not on the ACCEPTABLE PHYSICIAN SPECIALTY TYPES list (see attachment B1 and B2).
NOTE: If the source is on the acceptable sources list, and the only issue is the lack of a credential/specialty, then INV5 passes, but INV7 should fail.
• Question 7 (INV7) = Are you able to confirm an acceptable credential/specialty (e.g., MD, PA, DPM, Cardiology, Internal Medicine)? The
SE fails this check if the medical record is signed but there is no credential in the signature and no credential (MD, DO, NP) or specialty reference
(Renal, Cardiology, PCP, Hospitalist, Attending, etc.) to the one specific physician/practitioner named on the document (heading, defined provider
type in signature line). The INV is evaluated on a case-by-case basis in situations where the credential is implied in a pre-printed note designation
(doctors/provider notes). Note the SE does not answer this based on the presence of an attestation, only the medical record document.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
65
• Question 14 (INV14) = Is the date on the medical record within the data collection period? The SE fails this check if the medical record date of
service is not within the date collection period. If date cannot be determined (blank or illegible), question 14 passes as unknown, but INV4 fails.
• Question 15 (INV15) = Does the Provider Type of the medical record match the Provider Type selected on the Medical Record Coversheet?
SE fails this check if the medical record provider type doesn’t match the Medical Record Coversheet provider type. For example, the provider type
is marked as Inpatient but only a physician or outpatient record is attached. An exception is made for several pages of an inpatient record, which the
plan has identified as a physician/outpatient record on the Coversheet. The presence of the additional documentation in the inpatient is helpful to set
the context for assigning accurate codes for the one date of service selected. INV15 would not be failed in this case.
• Question 17 (INV17) = Is acceptable Medical Record documentation included? This is assigned when the submission includes a coversheet, but
the attached document is not a medical record. When INV 17 applies, all other INV flags are automatically assigned “no.” When plan checks no
record attached, the record does not move to intake, so no INV is flagged.
• Question 20 (INV20) = Miscellaneous INV: Is the record free from invalid issues not otherwise addressed through existing INV checks?
SE fails this check if there is a medical record issue that hasn’t already been identified in any of the INV questions.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
66
Appendix B1: Acceptable Physician Specialty Types Program Year (PY) 2014 – Numeric
Code Specialty Code Specialty Code Specialty Code Specialty
1
General Practice
19
Oral Surgery
40
Hand Surgery
79
Addiction Medicine
2
General Surgery
20
Orthopedic Surgery
41
Optometry
80
Licensed Clinical Social
Worker
3
Allergy/Immunology
21
Cardiac Electrophysiology
42
Certified Nurse Midwife
81
Critical care (intensivists)
4
Otolaryngology
22
Pathology
43
Certified Registered Nurse
Anesthetist
82
Hematology
5
Anesthesiology
23
Sports Medicine
44
Infectious Disease
83
Hematology/Oncology
6
Cardiology
24
Plastic and Reconstructive
Surgery
46*
Endocrinology
84
Preventive Medicine
7
Dermatology
25
Physical Medicine and
Rehabilitation
48*
Podiatry
85
Maxillofacial Surgery
8
Family Practice
26
Psychiatry
50*
Nurse Practitioner
86
Neuropsychiatry
9
Interventional Pain
Management (IPM)
27
Geriatric Psychiatry
62*
Psychologist
89*
Certified Clinical Nurse
Specialist
10
Gastroenterology
28
Colorectal Surgery
64*
Audiologist
90
Medical Oncology
11
Internal Medicine
29
Pulmonary Disease
65
Physical Therapist
91
Surgical Oncology
12
Osteopathic Manipulative
Medicine
33*
Thoracic Surgery
66
Rheumatology
92
Radiation Oncology
13
Neurology
34
Urology
67
Occupational Therapist
93
Emergency Medicine
14
Neurosurgery
35
Chiropractic
68
Clinical Psychologist
94
Interventional Radiology
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
67
Code Specialty Code Specialty Code Specialty Code Specialty
15
Speech Language
Pathologist
36
Nuclear Medicine
72*
Pain Management
97*
Physician Assistant
16
Obstetrics/Gynecology
37
Pediatric Medicine
76*
Peripheral Vascular Disease
98
Gynecologist/Oncologist
17
Hospice and Palliative Care
38
Geriatric Medicine
77
Vascular Surgery
99
Unknown Physician
Specialty
18
Ophthalmology
39
Nephrology
78
Cardiac Surgery
C0
Sleep Medicine
*
Indicates that a number has been skipped.
Appendix B2: Acceptable Physician Specialty Types PY 2014 – Alphabetic
Specialty Specialty Specialty Specialty Specialty
Addiction Medicine
Emergency Medicine
Internal Medicine
Ophthalmology
Podiatry
Allergy/Immunology
Endocrinology
Interventional Pain
Management
Optometry (Optometrist)
Preventive Medicine
Anesthesiology
Family Practice
Interventional Radiology
Oral Surgery (Dentists only)
Psychiatry
Audiologist
Gastroenterology
Licensed Clinical Social
Worker
Orthopedic Surgery
Psychologist
Cardiac Electrophysiology
General Practice
Maxillofacial Surgery
Osteopathic Manipulative
Medicine
Pulmonary Disease
Cardiac Surgery
General Surgery
Medical Oncology
Otolaryngology
Radiation Oncology
Cardiology
Geriatric Medicine
Nephrology
Pain Management
Rheumatology
Certified Clinical Nurse
Specialist
Geriatric Psychiatry
Neurology
Pathology
Sleep Medicine
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
68
Specialty Specialty Specialty Specialty Specialty
Certified Nurse Midwife Gynecologist/Oncologist Neuropsychiatry Pediatric Medicine Speech Language Pathologist
Certified Registered Nurse
Anesthetist
Hand Surgery Neurosurgery Peripheral Vascular Disease Sports Medicine
Chiropractic Hematology Nuclear Medicine Physician Assistant Surgical Oncology
Clinical Psychologist Hematology/Oncology Nurse Practitioner Physical Medicine and
Rehabilitation
Thoracic Surgery
Colorectal Surgery Hospice and Palliative Care Obstetrics/Gynecology Physical Therapist Urology
Critical Care (Intensivists) Infectious Disease Occupational Therapist Plastic and Reconstructive
Surgery
Vascular Surgery
Dermatology * * * Unknown Specialty
*
Left blank.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
69
Appendix C: Glossary
AHA – American Hospital Association
Alternative data sources – Alternative data sources (ADS) include diagnostic data from sources other than hospital inpatient, hospital outpatient, and
physician services. MA organizations may use ADS as a check to ensure that all required diagnoses have been submitted to CMS for risk adjustment
purposes, such as pharmacy records and information provided to national or state cancer registries. The MA organization may not, however, use ADS as
substitutes for diagnoses from a hospital/physician. As in all diagnoses submitted, there must be medical record documentation to support the diagnosis as
having been documented as a result of a hospital inpatient stay, a hospital outpatient visit, or a physician visit during the data collection period.
Amendment (to medical record documentation) – Source AHIMA corrections, amendments and addendum tool kit
An amendment is an alteration of the health information by modification, correction, addition, or deletion. There are many terms used that ultimately
amend the health record. For the purpose of this toolkit, the term “amendment” is the overarching term indicating that documentation has been altered.
There are many ways that a health record may be altered; these terms may include corrections, addendums, retractions, deletions, late entries, re-
sequencing, and reassignment. An amendment is made after the original documentation has been completed and signed by the provider. It should be noted
that unsigned documentation will have changes and then be signed, the changes made prior to the initial signature need to be tracked as well. All
amendments should be timely and bear the current date and time of documentation. Entries added to a health record to provide additional information in
conjunction with a previous entry. The addendum should be timely, bear the current date, time, and reason for the additional information being added to the
health record, and be electronically signed.
Attestation – A CMS-generated document that allows a physician to attest to his/her signature and/or credentials for a specific date of service for
outpatient/physician records only. Attestations are not accepted for inpatient records.
CDAT – Central Data Abstraction Tool
CMS – Centers for Medicare & Medicaid Services
CNS – Clinical Nurse Specialist
CON13, CON14 – Contract level RADV payment year 2013, 2014
DOB – Date of birth
DOS – Date of service
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
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DS – Discharge Summary
ED – Emergency Department
EMR – Electronic Medical Record
H&P – History and Physical
HCC – Hierarchical Condition Category
HIPAA – Health Insurance Portability and Accountability Act
HRA – Health risk assessments (HRAs) are medical record questionnaire forms that identify patient reported past, present, potential or chronic diseases,
injury risks, modifiable risk factors, and urgent health needs of the individual. HRAs may be documented through a telephone interview or web-based
program, during community-based prevention programs or during an encounter with a health care professional. The HRA may or may not be performed by
the patient’s regular provider and is often done by a physician or non-physician health professional contracted by the MAO specifically to perform this
function. The intention is to have the HRA reviewed by the patient’s provider in conjunction with other health records and testing to confirm, treat and
correctly report the potential conditions identified.
For purposes of RADV an HRA is valid as a medical record coding source if performed during a face-to-face encounter by a valid risk adjustment provider.
Diagnoses from HRAs not performed during a face to face encounter (e.g. telephone interviews or patient completed forms) must be substantiated in other
valid medical record documentation during a face to face encounter with a valid risk adjustment provider in order for the conditions to be coded and the
HCCs potentially validated.
ICD-9-CM, ICD-9 – International Classification of Disease, Ninth Revision, Clinical Modification
IP – Inpatient
Late Entry – Source AHIMA corrections, amendments and addendum tool kit.
An addition to the health record when a pertinent entry was missed or was not written in a timely manner. The late entry should be timely, bear the current
date, time, and reason for the additional information being added to the health record and be electronically signed. Typically, late entries apply to direct
documentation only; for example, physician orders, progress notes, or nursing assessments. Dictated reports such as history and physicals, although dictated
outside of organizational time frames, would not be considered a late entry. Note: Some systems may not have late entry functionality. The late entry is then
displayed as an addendum.
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
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MA – Medicare Advantage
N/A – Not applicable
NP, APRN, ACNP, ANP, FNP, GNP – Nurse Practitioner credentials
OP – Outpatient
PHI/PII – Personal health information/personal identifiable information
PA – Physician assistant
PA-C – Certified Physician Assistant
PA Credentials:
MPAP – Master of Physician Assistant Practice
MSPAS – MS in Physician Assistant Studies. Graduates from these master’s programs are eligible to sit for the national certification examination to
be licensed
Physician – The term “physician” is generally used throughout this document to refer to any of the acceptable physician data sources for risk adjustment
(see Attachment B1 and B2). Understand that several of these physician specialties (i.e., nurse practitioners, physician assistants, physical therapists,
licensed clinical social workers, etc.), are not physicians but are considered acceptable provider types/physician specialties for RADV.
POS – Point of service. A type of EMR where the provider logs in and enters notes directly into the patient’s medical record during the encounter.
QTR – Quarter (1, 2, 3 or 4), the publication yearly quarter for AHA Coding Clinic issues.
Query, Physician Query, Coder Query – Source: AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice. All professionals are
encouraged to adhere to these compliant querying guidelines regardless of credential, role, title, or use of any technological tools involved in the
query process. A query is a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome from
a query is an update [an “update” can be a late entry, addendum, or approved query form per individual facility medical record documentation policy] of a
health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment. The
final coded diagnoses and procedures derived from the health record documentation should accurately reflect the patient’s episode of care. In court an
Contract-Level RADV Medical Record Reviewer Guidance
10/24/18
The general guidance in this document is not exclusive. In addition to this guidance, all other rules, requirements, and instructions relating to medical
record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be
clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International
Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare
regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.
72
attorney cannot “lead” a witness into a statement. In hospitals, coders and clinical documentation specialists cannot lead healthcare providers with queries.
Therefore, appropriate etiquette must be followed when querying providers for additional health record information. The generation of a query should be
considered when the health record documentation:
o Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
o Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
o Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
o Provides a diagnosis without underlying clinical validation
A query should include the clinical indicators, as discussed above, and should not indicate the impact on reimbursement. A leading query is one that is not
supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure.
RADV – Risk Adjustment Data Validation
RAPS – Risk Adjustment Processing System
SE – Senior Evaluator. RADV medical record review contractor senior coder tasked with researching questions, confirming invalid cases from initial
levels of coders, and conducting a second level of coding.
SNF – Skilled Nursing Facility
