One of the most frequent questions to this blog is whether or not health plans can abstract ICD-9 codes from diagnostic radiology reports for risk-adjustment reporting.  The public guidance from CMS has been that such sources, whether institutional or professional-component are not acceptable for risk-adjustment.

“The following CPT codes indicate diagnostic radiology and other diagnoses that should not be submitted as risk adjustment data: 70010 through 76999 and 78000 through 78999″

“It is important for MA organizations to note that regardless of the type of diagnostic radiology bill (outpatient department or physician component), the services are not acceptable for risk adjustment.”

“CMS will not accept medical records for diagnostic radiology regardless of the type of bill (outpatient department or physician component) as support for data submission of a diagnosis. CMS recommends plans locate the medical record from the referring physician and determine if the diagnosis in question is based on the physician’s documentation in the medial record.”

*Quotes extracted from 2008 Risk Training guide and Feb 2008 CMS User Group Notes.

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