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The Necessity of Auditing in Value-Based Care: Ensure Compliance and Optimize Revenue

Who in your organization is responsible for assuring your documentation and submitted codes are correct? Do you have an auditing process in place? If not, you may be assuming that thousands of ICD-10 codes submitted to the Centers for Medicare & Medicaid Services (CMS) are 100% accurate, which may not be the case.

Reimbursement models are changing. Historically, in fee-for-service payment models, the patient assessment in the EHR, coupled with the plan of care, helped identify underlying conditions, the impact of those conditions, necessary treatments, and a patient’s prognoses. In today’s value-based care models, healthcare entities assume financial risk, so the assessment, diagnoses, and ICD-10 codes influence payments, particularly since ICD-10 codes are used to generate a patient’s Hierarchical Condition Category (HCC) risk score. In all primary care models, Current Procedural Terminology (CPT) codes continue to be important, as they reflect the intensity of evaluation and management provided. However, ICD-10 codes, which indicate a patient’s disease state and the severity of such, have assumed center stage. The specificity and accuracy of diagnostic statements, along with assigned ICD-10 codes, directly affect the healthcare entity’s compliance program and revenue.

So, how do you ensure your documentation and codes are correct? Chart auditing:

1. Ensures compliance

Auditing can ensure that diagnoses and accompanying ICD-10 codes are substantiated, meaning there is reasonable evidence that each diagnosis exists, was addressed, and was supported. This is necessary for submission to CMS for risk adjustment purposes. Submitting incorrect codes, particularly if they map to a Hierarchical Condition Category (HCC), violates the False Claims Act. It is important to note that an incorrect code does not necessarily indicate that the provider’s diagnosis was incorrect, but rather the ICD-10 code applied was in error. Additionally, diagnoses cannot be submitted by themselves without demonstrating that they were addressed in some fashion during the encounter. Without proper training in documentation excellence, providers may inadvertently upcode conditions, generating HCCs that are not correct. Therefore, it is important to have consistent auditing practices in place. Identifying and redacting upcoding and incorrect codes demonstrates to CMS that you are looking, and compliance is a priority to your organization.

2. Assists with claims integrity

If claims data and various CMS reports are available, an auditor can ensure that all the ICD-10 codes generated from an encounter are in CMS’s possession for the purpose of an accurate risk score calculation.

3. Can increase revenue
With a comprehensive review of the encounter, an auditor can uncover diagnoses that may exist but were either not captured or only partially captured due to non-specificity. By reviewing labs, diagnostic imaging reports, and specialist consultations, an audit can present potential diagnoses that can be captured during a later encounter with that patient, leading to a more optimal risk score.

Though performing audits internally is acceptable, outsourcing auditing to an independent company improves your organization’s credibility. Capstone Risk Adjustment Services provides auditing solutions for value-based care healthcare entities. Our auditing services, combined with our physician-led Clinical Documentation Excellence (CDE) education, can greatly improve your organization’s compliance and revenue.

We are proud to offer AAHCM members a 5% discount on a 12-month subscription to our on-demand physician-created Clinical Documentation Excellence education course, CDE Online. To find out more about our auditing solutions or CDE Online, email us at [email protected], visit, or call 844-683-5302.



George “Mike” Brett, MD
SVP Consulting Services, Chief Medical Officer
Capstone Risk Adjustment Services

About George W. Brett, MD
Dr. Brett has more than 30 years of experience in geriatric medicine and long-term care. Prior to joining Capstone in 2014, he served as the Medical Director for a PACE (Program for All-Inclusive Care for the Elderly) program in Southwestern Pennsylvania. As a private practitioner for more than three decades, Dr. Brett specialized in internal medicine and geriatrics and served as medical director for several long-term care facilities and hospice organizations, in addition to PACE. His work with PACE led to his interest and eventual expertise in Medicare risk adjustment. He is a frequent presenter on topics including polypharmacy in the elderly and Medicare risk adjustment.

In the move to home-based care, clinician experience matters more than ever


A recent piece published in the Journal of the American Medical Informatics Association discussed the current administration’s efforts to address clinician burnout and improve usability of and satisfaction with healthcare technology. While the article stresses three important areas of focus such as improved health IT system designs, enhanced system configuration decisions, and increased end user training during health IT implementation, it misses the mark on additional challenge areas – particularly as it relates to two significant shifts in how care is delivered.

As more providers and payers make the transition away from offices and hospitals to living rooms, they are increasingly looking to embrace new value-driven approaches to patient care.

The first shift is the move to home-based models of care and the second is the transition to value over volume – both go hand-in-hand to some degree. As more providers and payers make the transition away from offices and hospitals to living rooms , they are increasingly looking to embrace new value-driven approaches to patient care. These new approaches include, but are not limited to, longer visits that prioritize a holistic understanding of the patient while focusing on relationship building – and expanding the type of care team members in the patients’ home.

These changes and others associated with the move to home-based care models mean physicians and care teams need to fundamentally shift their practice of medicine – and in a good way. Still, change is never easy – especially amid a pandemic.

Healthcare organizations looking to adopt at-home, value-driven care models while supporting their clinical staff through this transition should carefully consider the appropriate role technology can play in simplifying these changes. More so, these organizations would be well-served to consider lessons learned from the widespread adoption of healthcare technology over the last decade and move to reduce, not increase, the administrative burden for providers.

If the end goal of value-based care is driving improved outcomes and reducing costs over time, we must “begin at the beginning” – with the doctor and the patient at the point of care.

As part of the strategy to streamline adoption of home-based, value-driven care, healthcare organizations should ensure clinicians have the tools and support to make these efforts successful. If the end goal of value-based care is driving improved outcomes and reducing costs over time, we must “begin at the beginning” – with the doctor and the patient at the point of care. Organizations that are adding new workflows, data and administrative duties to doctors are missing the point and are setting themselves up for failure. As one of my close physician friends recently shared, if it’s not in the current electronic health record workflow, he doesn’t want to have anything to do with it. Doctors simply don’t have additional time and mindshare to offer up to mediocre technology – even if it supports improved patient outcomes.

With much of the healthcare industry focused on bringing at-home models of care to market in support of the transition to value-based care, building on what we have learned from the pandemic, clinician experience matters more than ever. We need to collectively look to adopt technologies and best practices that are provider approved and focused on workflow. Doing so will allow clinicians and care teams to focus on making personalized, holistic, at-home patient care a reality – while reducing the mental drain associated with paperwork and technological challenges.



Curation Health helps providers and health plans navigate and scale from fee-for-service to value-based care. Our advanced clinical decision support platform for value-based care drives more accurate risk adjustment and quality program performance by curating and delivering relevant, real-time insights to the clinician and care team. For more information, visit