Why “Unlinked Chart Reviews” Are Raising Red Flags
As oversight of Medicare Advantage (MA) plans intensifies, the U.S. Department of Health and Human Services Office of Inspector General (OIG) has zeroed in on a specific compliance risk: unlinked chart reviews.
These are diagnosis codes that have been added to a beneficiary’s record during retrospective chart reviews but lack an associated, date-specific service record. In other words, there’s no direct evidence that a clinician evaluated the patient on a specific date to support the diagnosis—raising significant concerns about accuracy, documentation, and potential overpayments.
Why It Matters
Retrospective chart reviews can uncover legitimate conditions that may have been missed during routine documentation. However, when these reviews introduce codes that aren't clearly linked to a dated clinical encounter, it creates ambiguity about whether the diagnosis was actively managed or relevant during the payment year.
The OIG’s investigation signals growing scrutiny into coding practices that may inflate risk scores without sufficient clinical basis. In the agency’s view, diagnosis codes submitted for payment must reflect conditions that were:
Clinically evaluated or treated
Supported by documentation
Tied to a specific date of service
The Compliance Gap
The issue with unlinked chart reviews is their lack of a specific date or encounter to anchor the diagnosis. Even if based on valid medical records, without documentation of a face-to-face or virtual visit, there’s no clear evidence that the condition was assessed during the appropriate time frame. This fails to meet CMS’s standards for “data accuracy and completeness.”
Plans relying heavily on such retrospective practices are now in the OIG’s crosshairs. In recent audits, the OIG has questioned millions in risk-adjusted payments stemming from diagnoses added through unlinked reviews.
What Plans Should Do Now
Audit Chart Review Processes
Review internal policies and vendor relationships to ensure that retrospective reviews meet CMS guidelines, especially around linking diagnoses to valid encounters.
Ensure Date-Specific Documentation
Any diagnosis added from a chart review must be supported by a note tied to a clear service date and provider attribution. Ambiguous records may not hold up under audit.
Reinforce Front-End Documentation
Invest in real-time clinical documentation support like HCC coding software to minimize missed diagnoses during patient visits, reducing reliance on post-visit chart reviews.
Leverage Technology
Use coding platforms powered by AI in healthcare that focus on point-of-care accuracy and ensure diagnoses are properly linked to provider encounters.
Prepare for More Oversight
With CMS and the OIG aligning on tighter data integrity standards, MA organizations must adopt a proactive approach to compliance.
ForeSee Medical’s AI-powered risk adjustment software is designed to support compliant coding from the ground up. With real-time, point-of-care insights embedded directly into the clinical workflow, providers can identify and document chronic conditions during the visit—reducing the need for unlinked, retrospective chart reviews.
Our technology ensures that every suspect condition is backed by clinical evidence and tied to a specific date of service, aligning with CMS and OIG expectations. Whether you're adapting to HCC v28, navigating RADV audits, or simply striving for more accurate RAF scores, ForeSee helps you get it right the first time.
Blog by: The ForeSee Medical Team