Fecal impaction.
Polyneuropathy.
Reno-vascular hypertension.
These are diagnoses for which there is no firm, generally accepted definition.
You can call them “soft diagnoses.”
And you need to know what they are.
Why?
The recovery audit contractors know them, too.
And they will target their use for compliance audits.
These compliance audits can claw back revenue retroactive up to five years. Five years!
If you want to keep the revenue that you’ve already booked, and probably already spent, listen close.
Every time you use one of these “soft diagnoses”, make sure you are passing the “smile test.”
You’re going to have to explicitly document your reasoning behind the diagnosis.
You don’t have to go crazy, but you do have to have a justification.
Recovery auditors are looking for a financial return on time they invest in investigating you.
They’re looking for clinicians who submit these “soft” diagnoses with virtually no documented justification. Those are the easy ones to claim a clawback on. And remember, the RACs are essentially bounty hunters, they’re paid a percentage of the revenue recovered.
The passive documentation tools of most corporate EHRs probably won’t cut it. They’re pretty much “cookie cutter” and organizations have a fairly low interest in committing resources to customize documentation in a way that’s not “cloning.”
You’re going to have to do it yourself.
“Soft Diagnoses” are a red flag, but they’re also an important source of Medicare Advantage revenue for outperforming clinicians.
Use them wisely.