Certified Risk Adjustment Coder (CRC)

Which of the following is an example of fraud?

1. A. Reporting a diabetic manifestation to increase the risk score.

2. B. Submitting a record for a RADV audit which includes diagnoses that were not previously reported.

3. C. Training physicians to document causal relationships for manifestations for chronic illnesses when present.

4. D. Setting a policy to report all patients with DM and CKD as a diabetic manifestation.

The correct answer is: A. Reporting a diabetic manifestation to increase the risk score.

The example of fraud in this context involves reporting a diabetic manifestation solely to increase the risk score. This act represents an intentional misrepresentation of information for financial gain, which aligns with the definition of fraud in healthcare settings. When a healthcare provider knowingly overstates or inaccurately reports a diagnosis, it undermines the integrity of the coding system and can lead to inflated resource allocation or reimbursement. Accurate documentation and coding should reflect the true clinical status of the patient. By intentionally including a diabetic manifestation that doesn’t exist or isn’t clinically justified just to boost the risk score, the provider is not only engaging in unethical practices but also violating regulations designed to promote accurate and honest reporting. Other options presented involve practices that, while potentially questionable in their intent or execution, do not directly constitute fraud as they do not involve the willful misrepresentation of patient diagnoses for illicit financial gain. For instance, submitting a record for a RADV audit that includes diagnoses not previously reported could reflect poor documentation practices rather than outright fraud. Similarly, training physicians to document causal relationships or setting policies for reporting specific conditions can be related to improving risk adjustment processes but do not inherently involve deceit.