Diagnosing Danger: AI-Generated Diagnosis in Medicare Advantage Coding

Important Codes Mentioned

Key Takeaways

• resolved False Claims Act (FCA) allegations and agreed to pay $22,485,00 (Justice, U.
•   Although the Martin’s Point case did not involve generative artificial intelligence (AI), the practice of skewing codes to increase a risk adjustment score may be increasing due to AI programs that process through an algorithm, data documented in the medical record, and suggest diagnosis codes that might have been missed.
•     The potential liability could be serious and widespread, especially if such conduct results in higher MA risk adjustment payments.
•   False Claims Act Liability   AI-assisted coding that results in the submission of false or unsupported diagnoses may violate the FCA.
• Department of Justice policy, organizations and individuals (including coders, auditors, and potentially AI vendors) may be held responsible under the FCA for submitting or causing the submission of false and/or fraudulent claims to the government for reimbursement.
• Regardless, a human being should check the outputs against the content of the medical record for accuracy before a claim is submitted.
• Additionally, ensuring an organization’s compliance program is effective and adequate is essential to avoiding potential FCA liability.
•   In one high-profile example, the DOJ intervened in a case against UCHealth over an automated coding rule that allegedly “upcoded” emergency department encounters to the highest emergency department CPT® code (CPT 99285) based on the frequency with which hospital personnel checked a patient’s vitals.

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