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Retrospective Review RAF Score For CY2024
| S.No | ICD 10 CM Code | Flag | CMS-HCC-V24 | CMS-HCC-V28 | Diagnosis Description | Delete Record |
|---|---|---|---|---|---|---|
| 1 |
| Category | CMS-HCC-V24 | CMS-HCC-V28 | CY2024 | |||
|---|---|---|---|---|---|---|
| ICD10 | HCC | HCC | Pre-Audit | Post-Audit | ||
| RAF Score | MA Payment | RAF Score | MA Payment | |||
Handling the Missed Opportunities in Medical Coding with RAF Score Tools
A retrospective review is a crucial process in healthcare that takes place after patient care has been delivered and claims have been submitted to payers. This post-care evaluation often reveals important Hierarchical Condition Category (HCC) codes that were either missed or inaccurately submitted. By identifying these gaps, healthcare providers can ensure that all conditions are properly documented, leading to more accurate risk adjustment and reimbursements.
What is Retrospective Coding Review?
Retrospective coding review involves a thorough assessment of patient medical records after treatment has been completed and billing has been processed. The goal is to catch any health condition diagnoses that may have been missed during the initial round of coding. This process is especially beneficial for chronic conditions or complex diagnoses that may not have been fully captured in the initial coding submission. For instance, in Medicare Advantage programs, retrospective reviews are often used to uncover HCC codes that were supported by medical records but not initially reported, as well as codes that should not have been submitted because they did not meet documentation guidelines.
Identifying Documentation Issues
Since retrospective reviews occur after the fact, they often uncover longstanding clinical documentation issues. Unlike real-time reviews, this approach focuses on correcting errors after the claims have been submitted. This requires a secondary process to flag the affected charts and send the corrected HCC coding information to the payer.
Retrospective reviews are commonly used with Medicare Advantage programs due to the straightforward method for submitting retrospective coding adjustments known as the Alternate Submission Method (ASM). However, submitting these adjustments can become more challenging in ACOs and CPC+ programs, where the process is more cumbersome.
Ensuring Complete and Accurate Health Records
One of the key benefits of retrospective chart audits is their ability to capture any missed diagnoses that were documented but not initially coded. By reviewing medical records from the current fiscal year, healthcare providers can ensure that they have an accurate account of the patient’s health history, which is critical for proper risk adjustment.
Improving Risk Adjustment Accuracy
A retrospective chart audit helps uncover missed opportunities for accurate coding and risk adjustment. By identifying any health condition diagnoses that were overlooked, this process ensures that the medical record reflects the complete health picture of the patient. The ability to make retrospective chart audit is particularly important in Medicare Advantage, where accurate coding significantly impacts reimbursements.
Challenges with Retrospective Chart Review
While retrospective reviews offer valuable insights, the process can be challenging. Since they occur after initial claims have been submitted, there is often a delay in submitting corrected codes. Additionally, certain programs, such as ACOs and CPC+, make it more difficult to submit retrospective coding adjustments, adding complexity to the process.
You can use our RAF Score tools for retrospective chart review at our website and learn more about it.
