REFERENCE INFORMATION FOR RA PRACTICE

[AntoniaL]

Hello!
Can someone tell me where I can find the rules guiding RA practice? I have looked at the Medicare Managed Care Manual Chapter 7 that addresses risk adjustment and some of it is in there, for example requiring name of patient, date of service, etc., acceptable facilities, but I don't find other specific information related to problem lists, past medical history, signature requirements, in other words the finer points of RA practice. I would like to get to the source information to read it directly so that I can better understand the requirements and the rationale for them. I understand that some requirements are driven by individual insurance carrier guidelines, but there has to be a baseline for everyone.

Are there any books that you would recommend that instruct risk adjustment practice that would be helpful to have as reference material that could possibly fill in some of the blanks?

Thanks so much!

 

[Alicia Scott]

I would normally send you to CMS.gov but you found that information. The key is that signature requirements and lists for example are not really defined by CMS but by the MA plans themselves. For example, the MA plan I worked for would not allow us to pull a dx off a list and eSigs had to be at the bottom of the documentation or it would get an E/O code. That was a policy they had. CMS does not require that the esig. has to be at the bottom. Some EMR's (to my frustration) has the esig. at the top. Those finer regulations you are looking for will not be written in stone for you to find as they are internal.

So, the baseline you are looking for really is not out there. I would say best practices will be difficult to find.

We do talk about this type of thing in our course. Not for testing purposes but for real world knowledge. Other then that your best hope is to contact places like Optum who has the UHC contract and find if they will offer this information.