PurpleTools RAF — Risk Adjustment Coding Compliance Declaration

Purple Tools Medical LLC

Purpose

PurpleTools RAF is a physician-support software application designed to assist health care professionals in identifying, reviewing, organizing, and appropriately documenting diagnosis codes that may be relevant to CMS risk-adjustment methodologies.

PurpleTools RAF is intended to support accurate clinical documentation and coding. It is not intended to create diagnoses, encourage unsupported diagnoses, increase risk scores through inappropriate coding, or replace the independent clinical judgment of the treating health care professional.

Physician Clinical Judgment

The treating physician or other qualified health care professional retains sole responsibility for determining whether a diagnosis is clinically appropriate for a patient and whether that diagnosis should be documented or coded for a particular encounter.

PurpleTools RAF may identify existing diagnosis codes, highlight diagnoses associated with CMS-HCC risk adjustment, organize diagnoses, or identify potential coding opportunities based upon information available within the patient's electronic health record.

Any such identification, highlighting, sorting, or suggestion is informational only.

A diagnosis must not be selected, documented, added, retained, or submitted solely because:

  • it maps to a CMS Hierarchical Condition Category (HCC);
  • it increases a patient's RAF or risk score;
  • it may increase reimbursement; or
  • PurpleTools RAF identifies or displays it as a potential coding opportunity.

Requirement for Medical-Record Support

Any diagnosis selected by a health care professional must be supported by the patient's medical record and must comply with applicable ICD-10-CM coding requirements, CMS requirements, and other applicable Federal and State laws and regulations.

PurpleTools RAF does not authorize the use of diagnoses that:

  • the patient does not have;
  • are unsupported by the medical record;
  • are entered solely to increase risk-adjusted reimbursement;
  • misrepresent the severity or status of a patient's condition; or
  • otherwise constitute inaccurate, false, misleading, or improper coding.

Where PurpleTools RAF identifies a potential diagnosis based upon clinical information such as laboratory results, measurements, existing diagnoses, or other information contained in the electronic health record, the software does not independently establish that diagnosis.

The clinician must determine independently whether the condition exists, whether it is appropriate to document for the patient and encounter, and whether the documentation supports the corresponding ICD-10-CM code.

Risk-Adjustment Prompts and Coding Opportunities

Purple Tools Medical LLC specifically prohibits the use of PurpleTools RAF to prompt or encourage a health care professional to document a risk-adjusting diagnosis that the patient does not have or that is otherwise unsupported or inappropriate for the patient's clinical circumstances.

Risk-adjustment status is presented as informational data and must never substitute for clinical judgment or appropriate documentation.

Users are expected to reject any suggested or potential diagnosis that is not clinically appropriate or adequately supported.

Physician Authorization

PurpleTools RAF does not make the final clinical determination that a patient has a particular condition.

Where the software provides functionality that may facilitate addition of an ICD-10-CM diagnosis to an electronic health record, affirmative action by the authorized health care professional is required.

The health care professional remains responsible for reviewing and approving the diagnosis and associated documentation before it becomes part of the clinical record.

Accuracy and Compliance

Purple Tools Medical LLC intends PurpleTools RAF to be used consistently with:

  • applicable ICD-10-CM Official Guidelines for Coding and Reporting;
  • Centers for Medicare & Medicaid Services requirements governing Medicare Advantage risk-adjustment data;
  • applicable HHS Office of Inspector General fraud, waste, and abuse guidance;
  • the Federal False Claims Act and other applicable fraud and abuse laws; and
  • applicable professional, payer, contractual, Federal, and State coding requirements.

Purple Tools Medical LLC does not condone upcoding, unsupported diagnosis capture, falsification of clinical documentation, manipulation of patient risk scores, or submission of inaccurate diagnosis information for purposes of obtaining additional reimbursement.

User Responsibility

Users of PurpleTools RAF remain responsible for:

  • independently evaluating the patient's clinical condition;
  • determining the appropriate diagnosis;
  • ensuring that documentation supports the diagnosis;
  • selecting the appropriate ICD-10-CM code;
  • correcting or removing diagnoses determined to be inaccurate or unsupported; and
  • complying with applicable payer, CMS, Federal, State, and professional coding requirements.

Compliance Monitoring

Purple Tools Medical LLC will periodically review the functionality of PurpleTools RAF in light of material changes to CMS risk-adjustment requirements, ICD-10-CM coding guidance, and relevant HHS-OIG compliance guidance.

Functionality identified as creating an unreasonable risk of encouraging unsupported, inaccurate, or inappropriate diagnosis coding will be evaluated and, when appropriate, modified or removed.

No Government Endorsement

PurpleTools RAF has not been reviewed, approved, certified, or endorsed by the Centers for Medicare & Medicaid Services, the U.S. Department of Health and Human Services Office of Inspector General, or any other governmental agency.

References to CMS, HHS-OIG, CMS-HCC models, RAF methodology, or governmental coding standards are provided solely to describe the regulatory and coding framework within which the software is intended to operate.

Declaration

Purple Tools Medical LLC is committed to designing and maintaining PurpleTools RAF as a physician-support tool that promotes accurate clinical documentation and appropriate diagnosis coding while preserving the independent clinical judgment of health care professionals.

PurpleTools RAF shall not be used to generate, encourage, or facilitate unsupported diagnoses or inappropriate increases in risk-adjusted reimbursement.