Jun 9, 2026 · 28 min · 9 segments
There’s a quiet battle taking place, with no field hospitals for the sick and wounded, and no bloodshed. But the stakes are high, and the losses are unforgiving. It’s the battle of algorithms…
Penny JeffersonHost
Cheryl Erickson
Christine Geiger
Frank CohenGuest
Chuck BuckHost
Now it's time for the talk of the Tuesday Coding Report with a good friend, Christine Geiger.
As we know, healthcare fraud has been a frequent topic in the news lately.
If you're active on LinkedIn, I encourage you to follow the HHS Office of Inspector General if you aren't already doing so.
Last week, they posted about a new audit, this time involving the Medicare Advantage Program.
The headline read, CMS Potentially Overpaid Medicare Advantage Organizations, $462 Million, based on certain unsupported acute stroke diagnosis codes.
Now, as a super broad overview, CMS uses a prospective risk adjustment system to determine and adjust payments for enrollees based on their health status and demographic.
This hierarchical condition category, our HCC model, allows CMS to map diagnosis codes based on similarity, severity, and cost.
The plan enrollees' diagnosis codes for one calendar year, which is their service year, are used to determine the HCC and are used to calculate their risk score for the following calendar year, which is their payment year.
The audit report notes that in 2024, CMS paid around 760 MA organizations $494 billion dollars.
Now, this may occur when physician records assign acute stroke ICD-10-CM codes during the same service year without an acute stroke code assigned on an inpatient or outpatient hospital record.
This particular audit focused on service year 2020, where nearly 774,000 MA organizations submitted an ICD-10-CM acute stroke code.
After review, it was determined that three of these enrollees were not included in the audit sample because they weren't enrolled in the appropriate identified MA
Of those remaining 97 in the sample, all of the acute stroke diagnosis codes reported were not supported by the submitted medical record documentation.
In 68 of these cases, documentation noted that the patient had a history of stroke.
Now history of stroke, that code Z86.73 is not an HCC condition, whereas acute stroke is.
In 22 of the cases, documentation didn't support an acute stroke diagnosis.
Finally, there was one case that had an acute stroke code assigned rather than the documented hemiparesis following a stroke.
This case actually resulted in an underpayment to the MA organization.
Now it's time for the talk of the Tuesday Coding Report with a good friend, Christine Geiger.
As we know, healthcare fraud has been a frequent topic in the news lately.
If you're active on LinkedIn, I encourage you to follow the HHS Office of Inspector General if you aren't already doing so.
Last week, they posted about a new audit, this time involving the Medicare Advantage Program.
The headline read, CMS Potentially Overpaid Medicare Advantage Organizations, $462 Million, based on certain unsupported acute stroke diagnosis codes.
Now, as a super broad overview, CMS uses a prospective risk adjustment system to determine and adjust payments for enrollees based on their health status and demographic.
This hierarchical condition category, our HCC model, allows CMS to map diagnosis codes based on similarity, severity, and cost.
The plan enrollees' diagnosis codes for one calendar year, which is their service year, are used to determine the HCC and are used to calculate their risk score for the following calendar year, which is their payment year.
The audit report notes that in 2024, CMS paid around 760 MA organizations $494 billion dollars.
Now, this may occur when physician records assign acute stroke ICD-10-CM codes during the same service year without an acute stroke code assigned on an inpatient or outpatient hospital record.
This particular audit focused on service year 2020, where nearly 774,000 MA organizations submitted an ICD-10-CM acute stroke code.
After review, it was determined that three of these enrollees were not included in the audit sample because they weren't enrolled in the appropriate identified MA
Of those remaining 97 in the sample, all of the acute stroke diagnosis codes reported were not supported by the submitted medical record documentation.
In 68 of these cases, documentation noted that the patient had a history of stroke.
Now history of stroke, that code Z86.73 is not an HCC condition, whereas acute stroke is.
In 22 of the cases, documentation didn't support an acute stroke diagnosis.
Finally, there was one case that had an acute stroke code assigned rather than the documented hemiparesis following a stroke.
This case actually resulted in an underpayment to the MA organization.
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