Over the past few months in working with our clients, we have had multiple reminders of the importance of completeness and accuracy requirements for data submission to CMS and State agencies.  I want to focus my message this month on the need for PACE organizations (PO) to be alert to both internal and external processes regarding Risk Adjustment (RAPS) data reporting.  Part of your agreement with CMS is an attestation that you will

"Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis must be coded according to International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Guidelines for Coding and Reporting."

Along with this, CMS expects that:

• each PO will specify and implement procedures to ensure that only data from acceptable sources are submitted. 

• POs will conduct internal audits and/or hire external auditors to determine that diagnosis codes submitted meet risk adjustment submission requirements

• POs will delete submitted ICD-9 codes that are incorrect as soon as possible

• POs are responsible for all data submissions and their content, regardless of using third party vendors.

 We strongly recommend an annual review of your RAPS and Part D policies and procedures and QAPI plan to be sure that you are performing sufficient internal auditing and monitoring such that your compliance officer has no doubts about the accuracy and completeness of the data submitted.

Besides the regulatory requirements for PACE organizations, the OIG work plan for 2105 also places emphasis on data quality and specifically indicates the OIG will review medical record documentation to ensure that it supports the diagnoses submitted to CMS for use in CMS's risk-score calculations and determine whether the diagnoses submitted complied with Federal requirements.

We encourage PACE Organizations to make data integrity (completeness, accuracy and security) a high priority for your compliance and QAPI programs for 2015.