Centene MRA

2024 Guideline Training

Recorded Guideline Training

 Client Profile
Centene MRA 2024
Project Scope: Medicare Risk Adjustment
DOS to Reviewed: 2023-2024

Focus Area: CMS-HCC Only V24, V28

Reporting Frequency: HCC 1X per calendar year

Required Quality: 95%

This is an HCC 1X per calendar year capture project! This means each unique HCC should be captured once
per year of our DOS scope (2023-2024). We should be capturing the best one occurrence of each HCC. If you
have already coded an HCC with an error comment and you later find an opportunity to capture the same
HCC with no flag, you should capture the HCC with no flag.
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 Arch Rejection Reasons Definitions
Rejecting a Chart in
Incorrect Patient The chart belongs to a different member.
Arch
Comingled-Multiple Patients in File There is more than one patient record within
the chart.

• When reviewing a chart in Arch, coders need to

ensure the medical record meets the requirements
for a codable record.
• Charts should only be rejected when there is no
appropriate code complete option AND the rejection
reason applies to the ENTIRE chart!

GL Page 4
Error Comment Description Chart Level Code Level Error Comments
Unlinked Medication When diagnoses documented in
PMH/PL or documented as "history
of“ and is only supported by an
unlinked medication
• The following error comments are to be used in the
Unsupported
Conditions
Approved chronic conditions
documented only in the PMH/PL or
project when applicable.
history of and is not supported.
• Note: Chart level error comments should only be
used if the flag applies to the ENTIRE chart!
• Chart level error comments should only be appended
to charts without codes entered.

GL Page 4
Error Comment Description Chart Level Code Level Error Comments
No HCC Codes If no HCC codes are found in the
entire record

• The following error comments are to be used in the

No Valid Record
Found
The entire chart is missing face-to-face
encounters
project when applicable.
• Note: Chart level error comments should only be
used if the flag applies to the ENTIRE chart!
• Chart level error comments should only be appended
to charts without codes entered.

GL Page 4
Signatures
This project does not have a signature issue flag.
Diagnoses with a signature deficit should still be
captured.

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 • HPI – Approved chronic conditions can be coded without additional support
provided there is no conflict. Other conditions will require support. Use caution
when considering to code "history of" conditions. See GL page 10-13.
Substantiation • ROS - Approved chronic conditions can be coded without additional
support provided there is no conflict. Other conditions will require support. Do
not code conditions that are solely patient reported.
• A/P & PE – Conditions can be captured without additional support provided
there is no conflict.

• Cancers always require good support (active treatment, etc)

• Acute life-threatening conditions should not be captured in a primary care
setting.
• Status codes such as transplants and amputations can be coded from anywhere
in the visit provided there is no conflicting documentation.

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• Linking a medication to a condition from a PMH/PL or
documented as "history of" is acceptable for Medicare. In
some instances, a flag may be required. Please see next
slide.

• OTC medications should not be used as support unless the

Medication
condition is outside of the PMH/PL AND directly linked by
the provider as treatment

• If a medication is listed for the prevention of a diagnosis

(prophylaxis/ppx), the dx should not be coded as the dx is
being prevented not treated. However, if the medication is
to prevent a recurrence (ex: anticonvulsant to prevent
seizures), the dx may be coded.

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 Medication

9
 Medical Records Requirements
• Patient identifiers
• An approved document
• Acceptable provider type and specialty
Medical Records • Each patient encounter must stand alone
• Face-to-face encounter
Administrative
Requirements
Patient Identifiers
• If patient identifiers are not on every page, but you see evidence of a
continuous flow from page to page , code all applicable HCCs
• Approved qualifying identifiers include:

Patient Identifiers
& Medical Records
Requirements

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Medical Records
Administrative
Requirements

Acceptable Types
of Medical
Records

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• When insulin and Type 1 DM are documented do not
pick up Z794
• In the event the provider notes E118, DM with

Additional Guideline
unspecified complication, this can be coded if
addressed/assessed, with or without supporting
documentation
• In the event the provider notes E11.6XX DM with other
specified complication in the A/P or it is addressed in the
note, and there is no documentation for the "other
Notes
specified manifestation", this can be coded.
• It is acceptable to code the following "NEC" codes if
addressed or listed in the A/P with or without supporting Diabetes
documentation if the provider did not list the specific
complication with the ICD-10 description assigned to the
"NEC" code
The NEC guideline above is
for provider
documentation of these
NEC codes. Combination
coding by the coder will
require provider linkage to
abstract these NEC codes.

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• The causal link can be made from anywhere in the
note, which includes PMH and Problem List. When
making the causal link from Past Medical History or
Problem List, append the appropriate flag of
Unsupported Condition or Unlinked Medication. Additional Guideline
• Please note, a flag is not required when both
conditions are supported in the active part of the Notes
encounter. Refer to page 9 for supporting
documentation.
Diabetes Combo Coding

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• Inpatient Post-Op reports: only code from the post-op
dx list
Additional Guideline
• Inpatient consultations: Admit date is acceptable to
use as a consult date when document DOS is not Notes
provided
• Inpatient H&P: Admit date is acceptable to use when
document DOS not provided
• Diagnoses documented as suspected/likely/etc. may
be coded as confirmed from a discharge summary Inpatient
provided the diagnosis was not ruled out
• Hospital inpatient medical records need to have an
admit and discharge date documented in at least one
place in the record (face sheet, summary, discharge
orders, etc.)

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 • AKI – this is the standard abbreviation for acute kidney injury
Feedback from and should be interpreted as such unless the context indicates
differently
Centene MRA
Pilot • DM with Cataracts is noted as a chronic condition in the Centene
mapping sheet. It should be captured unless the documentation
indicates the cataract(s) are no longer present.

• We should not capture HCCs with an error comment if it can be

captured elsewhere in the chart without an error comment

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Thank you