How is the accuracy of diagnosis coding assessed in RADV audits?

The accuracy of diagnosis coding in RADV audits is primarily assessed through the examination of medical records against submitted codes. This process involves a thorough review of the documentation in the patient's medical records to ensure that the diagnoses reported on claims align with what is documented by healthcare providers. This is crucial for validating the authenticity and accuracy of the diagnoses, which in turn impacts risk adjustment calculations.

By scrutinizing medical records, auditors can confirm not only that the conditions reported are supported by clinical evidence but also that they are correctly coded according to standardized coding systems, such as ICD-10. This methodical examination provides a direct verification of the diagnosis coding, which is essential for ensuring compliance with regulatory standards and for maintaining the integrity of risk adjustment processes.

Other approaches, such as patient surveys and interviews, while valuable for gathering perspectives or understanding patient experiences, do not provide the clinical documentation evidence needed to validate diagnosis coding. Similarly, comparing coding practices among providers offers insights into different coding methods but lacks the specificity of verifying individual patient records. Financial reconciliation of claims data focuses on the monetary aspects of claims processing rather than on the clinical details necessary for coding accuracy. Thus, the examination of medical records against submitted codes stands as the most effective and accurate method for assessing coding accuracy in RAD