The Problem with Problem Lists

Problem lists are a problem because often they are not updated.

Over the last year, we have heard much about Medicare Advantage (MA) health plans being investigated or fined by the government for false claims. The government has focused on the reporting of unsupported chronic conditions and the reporting of acute conditions, such as acute stroke, that really should have been coded as “history of.”

Several individuals have reached out to me about reporting conditions on the problem list. Others have asked what to do when a MA payer rejects a claim and asks the provider to resubmit with a condition that’s on the problem list. So, let’s explore these three somewhat related issues. The reader needs to keep in mind that MA payers are paid more by the Centers for Medicare & Medicaid Services (CMS) for reported conditions, typically chronic conditions.

First, just because a condition appears on the problem list doesn’t mean that the provider addressed it during the encounter. We all know that problem lists are a problem in themselves, because often they are not updated, and some conditions listed on the problem list have long ago been resolved and are no longer active.

Second, every encounter’s documentation must stand on its own. We should expect that the encounter’s documentation supports MEAT – M for monitoring, E for evaluating, A for assessing, and T for treatment – for any condition that is reported on the claim. Although most electronic health records automatically pull in the problem list to populate the encounter note, if the MEAT documentation is not there for each of the conditions, then only those conditions that are recorded and supported by the provider’s documentation should be coded.

When payers reject claims or ask providers to add conditions to their claims, compliance should be our coding professionals’ first priority. Was the condition addressed during the date of service in question by the payer? Was any element of MEAT recorded in the documentation? Is there any relationship between the conditions coded and the condition(s) being questioned by the payer? Should the provider be queried to determine if the questioned condition was addressed during the encounter? And, if so, should your provider add an addendum to their note? Or should you just tell the payer “no”? 

Adding diagnoses was one of the reported violations of a large provider-based MA plan. However, in this case, this organization “defrauded Medicare out of about $1 billion by altering patient medical records to add diagnoses after the fact that either didn’t exist or were unrelated to patient visits, the Department of Justice alleged.”

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) lists in its top 25 recommendations to reduce healthcare fraud its intention to provide targeted oversight of Medicare Advantage organizations. To stay out of the OIG crossfire, our coding professionals need to uphold the integrity of each claim by ensuring our claims are supported by the documentation that occurred at the time of the patient’s visit – and they just need to say “no” when they are being pressured to do something that is not compliant.

Programming Note: Listen to Rose Dunn when she reports this story live today during Talk Ten Tuesdays with Chuck Buck at 10 Eastern.