Member diagnosis codes are an increasingly critical data point used to calculate payments in risk adjusted payment models, measure quality, and for organizations to better understand the populations they serve.
For Medicare Advantage health plans the consequences of inaccurate diagnosis codes are significant. Poor documentation practices can lead to a health plan being under-reimbursed for that member, negative findings in Risk Adjustment Data Validation (RADV) audits, and the appearance of quality measure gaps that have already been closed.
SCIOClarity Chart Validation is a retrospective strategy wherein SCIO’s experienced staff coordinates the retrieval and auditing of member medical records from provider groups to maximize diagnosis code accuracy.
The service is used by health plans as a part of their overall efforts to ensure optimal performance in their risk adjustment and quality programs.
Common Diagnosis Code Documentation Errors:
- Mistranslating physician notes to ICD-10 codes
- System limitations on the number of diagnosis codes that can be included
- Codes dropped during transmission between stakeholders