June 2010

Medicare risk adjustment data validation


The Centers for Medicare & Medicaid Services (CMS) performs annual data validation audits to verify that information submitted by Medicare Advantage organizations is supported by the patient's medical record documentation. This ensures the integrity and accuracy of risk-adjusted payment to the Medicare Advantage organization.

We expect CMS to notify us this summer if any Asuris members are included in the next data validation audit. If our members are included, we may request medical record documentation from your office. The documentation will then be forwarded to CMS to complete the audit.

Accurate risk-adjusted payment relies on the diagnostic coding derived from the patient's medical record and is based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes.

It is important for the provider to:

  • Accurately code each encounter.
  • Clearly indicate that all diagnoses were addressed and reported.
  • On the claim, include the ICD-9-CM code of every diagnosis that was assessed, treated or considered in the medical decision making for that encounter.
  • Report codes only if they were actively addressed (not merely appearing on a problem list).
    • Chronic conditions that are being medically managed should be reported, even if they are not the principle reason for the patient's visit that day. This can be done when reviewing, updating or reconciling a patient's medication list.
    • Contributory and co-morbid conditions should be reported if they impact the ongoing care for the patient and were, therefore, addressed at the visit, but not if the condition is inactive or immaterial.


Additional documentation reminders:

  • Use only standard medical abbreviations.
  • The medical record must be complete and legible.
  • Use subjective, objective, assessment, and plan (SOAP) note format when applicable.
  • Record the patient's name and date of service on each page of his or her chart.
  • Update all acute and chronic diagnoses with the current status and treatment plans in the progress notes.
  • Include the provider's signature and credentials (either handwritten or electronic) on each chart entry. Dictated/transcribed entries also require the provider's signature (either handwritten or electronic). Stamped signatures are not acceptable.


We encourage you to review additional information (PDF).


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