We need to add or delete diagnoses from an already-submitted encounter data record. Are we allowed to change the diagnoses from what was submitted on the bill, or do we need to have the provider rebill the plan?


Answer:

Since the Encounter Data Record (EDR) is a report to CMS from the MAO or other entity about an item or service received by the plan enrollee, the MAO or other entity can report to CMS the data they know to be correct relative to the provision of that specific item or health care service being reported. Per CMS guidance, diagnoses reported to CMS for risk adjustment must meet risk adjustment rules, including that they must be supported by the medical record. As with Risk Adjustment Processing System (RAPS), if an MAO or other entity determines that diagnoses need to be deleted because they are not supported by the medical record, there are a number of ways to delete diagnoses from the encounter data system, including chart review delete records, replacing with an EDR with the unsupported diagnoses removed, or voiding an EDR.

Source: CMS HPMS Memo with subject “Guidance for Encounter Data Submission” (October 30, 2017)

Last Updated: 10/30/2017