Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) – Part 1

Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) – Part 1

  • 28 Aug 0
  • Share

Capstone LogoCorrecting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 1

By: Dr. Richard Schamp, MD

PACE Organizations (POs) face many compliance issues regarding their data submissions to regulatory agencies.  Risk Adjustment data is just one of the many areas where care is needed.  For example, POs are required to attest annually regarding risk adjustment data accuracy.

  • MA plans must certify that risk adjustment data is accurate, complete and truthful (based on best knowledge, information, and belief) (42 C.F.R. § 422.504(l))
  • This creates a duty to, at a minimum, “put in place an information collection and reporting system reasonably designed to yield accurate information,” including ordinarily conducting “sample audits and spot checks . . . to verify whether [the system] is yielding accurate information” (64 F.R. 61893, 61900 (Nov. 15, 1999))

CMS expects its contractors, including POs, to self-police and self-report regarding compliance with regulations.  This concept was reinforced in a HPMS Memo issued late February 2013 on the subject of “CMS consideration of self-disclosure by plan sponsors of non-compliant conduct in the determination of compliance actions”:

              Since 2006, CMS has consistently advised Medicare contractors to report voluntarily to CMS any instances of program non-compliance that they discover on their own. As CMS staff have stated in numerous presentations to industry, we look more favorably on Medicare contractors when we learn of their non-compliance from them rather than through other means… CMS believes that self-reporting can be seen as evidence of an effective compliance program, indicating that while some non-compliance has occurred, the contractor has capable management and oversight in place exercising effective control over the organization.

          Self-reporting is one of several factors… that CMS considers when assessing compliance. Also, the absence of self-reporting may qualify as an aggravating factor, as CMS may issue a higher level of compliance notice when a Medicare contractor fails to self-report non-compliant conduct.

So, besides assuring compliance and effective QI processes, there is a positive side to doing the right things in regard to self-disclosure and error corrections.

Standards of Data Accuracy Require Correcting Errors.

Some examples of regulatory language underscore the requirements for error correction.

  1. PACE plans must filter risk adjustment data to ensure diagnosis submissions comply with CMS’s MA “guiding principles” (e.g., face-to-face encounter, in accordance with diagnosis coding guidelines, acceptable provider type and physician specialty) (CMS 2008 MA Participant Guide § 4.11)
  2. PACE plans must “ensure the accuracy and integrity of risk adjustment data submitted to CMS . . . [and] if upon conducting an internal review of submitted diagnosis codes, the plan sponsor determines that any . . .codes have been erroneously submitted, the plan sponsor is responsible for deleting the submitted . . . codes as soon as possible” (Medicare Managed Care Manual § 40)
  3. PACE organizations are required to delete records when an erroneous diagnosis cluster has been accepted by CMS (CMS 2008 MA Participant Guide § 4.16)


What Kinds of RAPS Errors Need Correction?

There are occasions where plans will need to delete diagnosis clusters. Here are some reasons for deleting the clusters.

  1. Diagnosis clusters submitted erroneously (e.g., data from an interim bill was submitted for hospital inpatient, type of bill 112 / 113. When TOB 114 has been received.), therefore, plans should correct the previously submitted claim with the corrected diagnosis clusters.
  2. Incorrect HIC number used for submission on a beneficiary’s claims
  3. An error in a diagnosis cluster field (i.e., “Provider Type,” “Dates of Service,” “Diagnosis Code”), such as when it is discovered upon review that a diagnosis code is not supported by the documentation, for example.  Another common situation is when ineligible diagnosis codes are submitted in error through a faulty electronic extraction process from EMR notes.


PACE Organizations must have established processes in place for internal auditing and monitoring that help them to detect errors.  These procedures are often described in the Part D Fraud, Waste and Abuse policy and are a routine part of corporate compliance functions.


Next time – How to correct errors in RAPS.



-2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide

-CMS Memorandum of  February 27, 2013 on CMS consideration of self-disclosure by plan sponsors of          non-compliant conduct in the determination of compliance actions

-Electronic Code of Federal Regulations (e-CFR) —  42 C.F.R. § 422.504(l)

-Federal Register – 64 FR 61893 – Publication of the OIG’s Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plans

-Medicare Managed Care Manual, Chapter 7 – Risk Adjustment § 40


*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.