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    MGMA Staff Members

    The significant changes for outpatient and office visit E/M coding in 2021 remain an ongoing concern for medical group leaders to ensure accurate and compliant coding into the new year.

    That message came from Beth Wolf, MD, CPC, CCDS, medical director for health information management, Roper St. Francis Healthcare, Charleston, S.C., and Colleen Deighan, RHIA, CCS, CCDS-O, ambulatory consulting services manager, 3M HIS Consulting Services, during their presentation at the 2021 Medical Practice Excellence: Leaders Conference.

    Outlining the 2021 changes (see Table 1), Deighan called the moves affecting coding and documentation for office and other outpatient services an effort “around simplifying the work” for providers to have the work “be more in line with how physicians think.”

    But physicians, providers and medical group staff increasingly must think about value, as reflected in the separate hierarchical condition categories (HCC) risk-adjustment methodologies developed by the Centers for Medicare & Medicaid Services (CMS) and the Department of Health & Human Services (HHS), with the CMS HCC system focused on the Medicare population and HHS’ system designed for all ages in the commercial payer population, as well as some Medicaid plans and ACA marketplace plans. The proliferation in risk adjustment also is buoyed by the extraordinary growth of Medicare Advantage (MA) plans in recent years, Deighan added: “MA enrollment more than doubled in the past decade and is projected to add another 10 million enrollees over the next eight years.”

    That’s why “complete and accurate coding of HCCs is critical to proper payment,” Deighan continued. HCCs, directly and indirectly, factor into several value-based programs, including MACRA program payments, bundled payment programs, accountable care organization (ACO) shared savings and annual capitated payments.

    The need for compliance

    With this surge in risk-adjusted payment comes government audits. CMS is required to conduct risk adjustment validation (RADV) audits — some are random audits of MA plans, while others are targeted audits (using a stratified sample of patients) of MA plans that have raised red flags, such as significantly large increases in risk scores, Deighan said. “The focus is not on proving the ICD-10 coding, but rather providing the validity of the HCC value that was paid to the health plan by CMS for the reported ICD-10-CM diagnosis codes,” Deighan said.

    Wolf offered the example of an established patient who has not been seen for a year to underscore the complexity of what qualifies as accurate and complete documentation of HCCs (see Table 2).

    For the scenario outlined in Table 2, physician codes would include K52.9 (gastroenteritis, unspecified), C67.9 (bladder cancer, unspecified) and I73.9 (PVD, unspecified). The 2021 E/M changes apply in the case of this established patient’s office visit, so the MDM elements of problems, analysis and risk are used to help level the E/M service. In this instance, it leads to code 99214 (30-39 minutes, established patient visit) based on moderate leveling:

    • Problem: based on one acute illness with systemic symptoms
    • Analysis: Category 1 (at least three tests ordered)
    • Risk: prescription drug management is present.

    To then capture the patient’s RAF, the gastroenteritis — not part of HCC coding — is stripped away to only focus on codes C67.9 (covered in HCC 11 with an RAF value of 0.307) and I73.9 (HCC 108, with an RAF value of 0.288). Adding those values to the patient’s demographic score of 0.3 yields a total RAF of 0.895, which then might yield about $716 in per member, per month (PMPM) payment.

    HCC documentation requirements

    • An HCC diagnosis must be captured in a face-to-face visit by a physician or an advanced practice provider (APP) [e.g., nurse practitioner (NP), physician assistant (PA)]
    • All diagnoses must be properly documented in the medical record
    • Supporting clinical evidence for all diagnoses built on the claim must have supporting clinical evidence, which often uses the MEAT (monitor, evaluate, assess, treat) criteria. Visit for more on MEAT criteria.

    Unfortunately, an auditor looking at that chart would not see any of the MEAT criteria being met, as all the monitoring, evaluation, assessment and treatment was related to the gastroenteritis. Therefore, any of the RAF values for the other two codes would be stripped away, leaving only the patient demographic score, which is worth about $240 in PMPM.

    However, there are many questions left unanswered in this patient record, Wolf noted:

    • What about the cancer? Was it removed, or is there active treatment?
    • Is ureterostomy still present?
    • There were no comments on the vital signs or the creatinine levels, even though they might be significant findings (especially given reference tools for diagnosing acute kidney injury, which would say that the creatinine levels meet the threshold criteria).

    By starting to answer these questions, the assessment/plan takes on a new look (Table 3). Acknowledging the acute kidney injury and having a discussion with the patient about the hypotension add details that satisfy MEAT criteria, and clarifying the history of bladder cancer further rounds out the true picture of this patient’s health.

    As for the peripheral vascular disease (PVD), the atherosclerosis in the extremities could also be in vessels leading to the intestines, which could be bowel ischemia, which has not been ruled out, Wolf noted.

    This new documentation no longer yields the moderate 99214 code, but instead the higher-acuity, longer-time 99215 code, as the problems and risk E/M factors are now high while analysis remains moderate. That 99214 code’s 1.92 RVU value (for 2021) instead has a 2.8 RVU value following the 2021 changes in RVUs.

    Those updates also will yield increased payment when the RAF accounts for HCC 135 (acute renal failure, with an RAF value of 0.435) and HCC 188 (artificial openings for feeding or elimination, with an RAF value of 0.534). The previous 0.895 total RAF has now almost doubled, to 1.557, which produced about $1,245 PMPM instead of $716 PMPM. If several patients across the practice see RVU and PMPM gains such as this in 2021, this makes the practice a prime target for an audit, Wolf cautioned.

    Quantifying risk

    Patient risk adjustment factors (RAFs) represent a total score of all relative factors related to one patient for a total year. This is done by taking demographic risk scores (based on factors such as age, residence, Medicaid disability and its interaction with age and/or gender) and multiplying them by disease risk scores (e.g., reported HCC diagnoses and factors for interactions between disease categories). “Accurate and appropriate HCC reporting, representing true patient severity of illness and disease progression year over year, is critical to accurate payments,” Deighan said.

    Understanding compliance audits

    The HHS Office of the Inspector General (OIG) is responsible for audits, investigations and evaluations, with a focus on data integrity, the accuracy of encounter data and denied services, especially with MA plans, Deighan said, as federal requirements mandate that payments to MA plans be based on the anticipated cost of providing Medicare benefits to a given enrollee.

    Additionally, risk adjustment data also is audited, as inaccurate diagnoses can cause improper payments. “CMS estimates about 9.5% of payments to MA plans are improper, mainly due to unsupported diagnoses,” Deighan said.

    Recent enforcement

    • In April 2021, OIG performed a sample audit of 200 enrollees in Humana MA plans with at least one diagnosis code that mapped to an HCC, and the company provided medical records for support of the 1,525 HCCs associated with those enrollees. Following an independent medical review, the audit found most of the diagnoses submitted were supported, but only 1,322 of the 1,525 HCCs were validated. Based on the lower risk score of the 1,322 validated HCCs, the OIG estimated that Humana received about $197.7 million in net overpayments for 2015.1 Deighan noted that the OIG recommended that Humana refund that amount and enhance its policies and procedures to prevent, detect and correct instances of noncompliance; however, Humana disagreed with these findings and questioned OIG’s methodologies for statistical sampling used in the audit.
    • The Department of Justice (DOJ) filed a lawsuit against Cigna in 2020, alleging $1.4 billion in false MA claims submitted between 2012 and 2017 based on whistleblower claims of improper diagnostic codes used to “coax CMS into paying a higher capitated rate.”2
    • Sutter Health in California and various affiliates agreed to pay $90 million to settle False Claims Act allegations of mischarging the MA program. This settlement included the organization entering into a five-year corporate integrity agreement with the HHS OIG to, among other things, incorporate a centralized risk assessment program and annually review a sample of the organization’s MA patient records and diagnoses data through an independent review organization.3

    The roles of review and compliance management

    Clinical documentation improvement (CDI) specialists can help clinicians get these complex coding issues correct prior to submitting claims, but the feasibility often varies in different settings. Wolf noted that clinical documentation specialists in hospitals often have “a fair amount of time” to review a chart compared to the time available in an outpatient setting.

    Pre-visit reviews of patients’ history often can be the first step toward ensuring the right elements go into selecting HCCs and getting to an RAF that can withstand the scrutiny of an audit. Reviewing past patient notes can lay groundwork for determining if the patient has a history of the issue or if the condition is current. “We’re going to be prompting the physician to have a heightened level of awareness for potentially documenting, diagnosing and managing” these issues, Wolf said.

    With that enhanced focus on documentation, the organization can build a strategy to remain compliant as regulatory guidance for HCCs and E/M services evolve into the future. “It really begins with an assessment — analyzing data, validating the data with a record review,” Deighan said, and taking a close look at the people in those workflows and how their work might change upon implementation of an HCC program or an E/M validation prior to claim submission. In some cases, it might mean making more time for physicians to spend with patients.

    “Supporting the workflow changes with monitoring and coaching are big pieces of an implementation program and success” to be sustainable, Deighan said, so that there are fewer issues as ongoing measuring and monitoring of RAF scores occurs.

    It also requires a good degree of physician buy-in for those who aren’t accustomed to this approach. “Most of our doctors in the outpatient setting assign their own E/M services, [and] very little of that today is validated,” Deighan cautioned, adding that it requires looking beyond traditional measures of success. “Physicians are very close to their RVUs, so this requires collaboration and communicating to physicians why this matters.”


    1. HHS OIG. “Medicare Advantage Compliance Audit of Diagnosis Codes that Humana, Inc. (Contract H1036) Submitted to CMS.” April 2021. Available from:
    2. “DOJ brings lawsuit against Cigna for allegedly submitting $1.4 billion in false Medicare Advantage claims.” Healthcare Finance. Aug. 6, 2020. Available from:
    3. DOJ. “Sutter Health and Affiliates to Pay $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Program.” Aug. 30, 2021. Available from:

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