Pre-Submission Code Validation
Validate codes before submission to prevent compliance issues:
Code Validity
Verify codes are valid for the service date and payment year.
Documentation Support
Confirm clinical documentation supports each submitted code.
Provider Qualification
Ensure diagnoses come from acceptable provider types.
Encounter Requirements
Verify face-to-face encounter requirements are met.
Audit Risk Indicators
Identify patterns that may trigger audit scrutiny:
- Rapid RAF growth: Unusually fast increases in risk scores
- High-value HCC concentration: Disproportionate coding of high-coefficient HCCs
- One-way coding: Adding HCCs without corresponding deletions
- Provider outliers: Providers with RAF patterns significantly above peers
- Chart review discrepancies: High deletion rates in internal audits
Common Compliance Gaps
Address these frequently identified compliance issues:
- Missing MEAT: Conditions coded without Monitor, Evaluate, Assess, Treat documentation
- Specificity mismatches: Code specificity not supported by documentation
- Resolved conditions: Coding conditions that have been resolved
- History code errors: Using active codes for historical conditions
- Linkage failures: Symptoms coded without definitive diagnosis linkage
Reconciliation Against CMS Feedback
Use CMS feedback reports to validate and improve coding:
- MAO-004 reports: Review accepted vs rejected HCCs
- RAPS return files: Analyze rejection reasons and patterns
- Encounter data feedback: Reconcile encounter submissions
- Payment reconciliation: Compare expected vs actual RAF payments
Ongoing Reconciliation
Regular comparison of submitted data against CMS acknowledgments and payment reports.
Final Reconciliation
Year-end validation against final CMS payment calculations and feedback.
Compliance Tools
ICD-10 Guideline Auditor API
ICD-10 guideline auditor API for automated compliance validation.
ICD-10 Code Lookup API
ICD-10 code lookup API for coding accuracy.
Payer Audit Readiness Analytics
Payer audit readiness analytics and risk detection tools.
RADV Scrubber
RADV scrubber for pre-submission validation.