HHS-RADV Lessons Learned


It’s a new year and things are gearing up the Benefit Year 2017 HHS-RADV audit. Here are few things to keep in mind as you, the Issuer, prepare for the coming audit.

  1. Treating Provider

Look for records from providers that are treating the condition/disease that corresponds to the HCC.  For example, if the HCC is for Diabetes, send a record from a physician that is treating this condition such as a Family Medicine, Internal Medicine-Endocrinologist or other primary care provider.  The best record to substantiate a condition is from a provider who is actively treating that condition. Remember, it is not enough to just state a patient has a condition, there must also be evidence the condition is active and being treated.

  1. Valid signatures

Only provide records with valid signatures.  Un-authenticated documentation is not acceptable and will result in a fail.

  1. Complete Records

For an inpatient record, send the discharge summary along with the H&P, consultations, and progress notes.  Partial records may provide only a partial picture of the patient’s condition(s) and treatments. Additionally, diagnoses on admission that were ruled out do not qualify for an abstraction, and without complete documentation (a discharge summary), correct coding cannot be accomplished.

  1. Conduct Mock Audits

Regularly conduct mock IVA- type audits to uncover potential areas of risk.  All coders are not created equal.  There is wide variation in coding training and experience which can be problematic for providers as well as issuers.  Collect and review records from the perspective of an auditor.  Play devil’s advocate- really pick the documentation apart looking for discrepancies, omissions, and points of conflict.  Coders cannot infer a condition exists based on a set of criteria; a qualified diagnosing provider must state a condition is present.  Look for instances where a condition is described in multiple ways in the same encounter record.  Work with physicians to resolve any conflicting information so the diagnosis or condition is clear.

  1. Pay attention to dates

Historical conditions that no longer exist do not qualify as an active diagnosis under the ICD10 Coding Guidelines. For example, a final diagnosis list may state Acute NSTEMI as a diagnosis, but in reading the record, this occurred at a prior time (sometimes years earlier).  This should not be coded.  Many conditions can be sporadic, come and go or happen one time and disappear forever. If a condition is not currently being treated and/or is not impacting current care in any way, it should not be coded.  The point of this audit is to capture conditions that are impacting care and consuming resources in the year being audited.