Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 2

Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 2

  • 06 Sep 0
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Capstone LogoCorrecting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 2

By: Dr. Richard Schamp, MD

Our previous article described the importance of identifying and correcting errors in submitted data such as RAPS files.  Today, we review how to correct the errors.

The Risk Adjustment Processing System at CMS allows for the correction of risk adjustment data submitted to CMS. This correction process is based on the concept that the incorrect cluster must be deleted from the system before the correct cluster is added. For this reason, data correction is at least a two-step process.

Each diagnosis cluster is stored separately as a unique cluster associated with a beneficiary’s HIC number. If a diagnosis was submitted in error and needs to be corrected, the original diagnosis cluster must be resubmitted with a delete indicator in the appropriate field.  When a delete record is received, CMS maintains the original diagnosis cluster on file and adds a delete indicator to it and the date of the deletion.

PACE organizations submit deletions within a file, batch, or record containing previously submitted risk adjustment data.

 Steps for Deleting a Diagnosis Cluster

Before deleting an error, verify that the diagnosis cluster appears on the RAPS Return File. Only diagnosis clusters accepted by RAPS and stored in the RAPS database may be deleted.

There are two methods for deleting diagnosis clusters:

Method 1

  1. Submit RAPS format using normal submission process with appropriate HIC number included.
  2. Enter information in the diagnosis cluster fields exactly as it appeared in the original submission.
  3. In field 9.3 enter a “D” for delete.
  4. Enter the appropriate information in all other records to ensure the submission file is complete.
  5. Transmit the file to FERAS. (See www.csscoperations.com for details.)

Method 2

  1. Create a file using the Direct Data Entry (DDE) screens available through FERAS at Palmetto (detailed information about the DDE process is located in Section 4.20 of the 2008 RAPS Participant Guide).
  2. Enter information exactly as it appeared in the original submission.
  3. In the DDE “CCC” record screen, hit the down arrow key and select “D.”
  4. Proceed with entering all appropriate information.
  5. Upload the file created in DDE to FERAS at Palmetto.

 Additional Considerations

  • If the PACE organization submits corrected data, they must submit the appropriate deletion record. That is, if the correct diagnosis cluster is submitted, the erroneous diagnosis cluster cannot be ignored.
  • If a correction applies to the same beneficiary as the deletion, the correction may be included in the same “CCC” record as the deletion.
  • If only one of several clusters within the CCC record requires modification, do not resubmit all other associated clusters. If clusters are resubmitted exactly the same without the delete indicator, the plans will generate a duplicate cluster error.
  • If the corrected diagnosis cluster belongs to a different participant than the deleted diagnosis cluster, the correct diagnosis cluster may be submitted in the same file as the deletion.
  • MA organizations should not delete a diagnosis code or record repeatedly on the same day and on the same record. MA organizations should implement a process to ensure that only one instance of a specific diagnosis cluster (either add or delete) is submitted on a given day.
  • These processes should be incorporated into the PACE Organization’s internal auditing and monitoring policies and procedures and also detailed in the fraud waste and abuse policy.

 

*The information presented here complies with accepted coding practices and guidelines as defined in the ICD-9-CM coding book. It is the responsibility of the healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM code(s) according to the official coding  guidelines.

*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.

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