21 Jan 0
Enrollee Risk Assessment Code in RAPS Starts Jan 1, 2014
Effective for dates of service starting 1/1/2014, risk adjustment data (RAPS files) submitted by PACE organizations and MA plans are accepted only if the new field “Risk Assessment” is populated.
The Risk Assessment field must contain one of the following values:
A. Diagnosis code comes from a clinical setting (i.e, not done in a patient’s home)
B. Diagnosis code comes from a non-clinical setting (i.e, not done in a patient’s home) and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit (including the Welcome to Medicare visit) were met.
C. Diagnosis code comes from a non-clinical setting and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit (including the Welcome to Medicare visit) were not met.
The requirements for a First Annual Wellness Visit and Subsequent Annual Wellness Visit and Welcome to Medicare visit are defined in regulation at 42 CFR 410.15(a).
Most likely, PACE organizations’ RAPS data will nearly always use an “A” in this field, but programs should be alert to situations when another code is more accurate.
The new RAPS file format requires that one of the three acceptable Risk Assessment Codes is assigned to each cluster. Errors are returned for anything other than an acceptable code in the Risk Assessment Code field if the date of service is 1/1/2014 or greater. We recommend all plans confirm with their TPA or software vendor (if self-submitting) that this requirement is satisfied, to avoid rejection errors.
There are no certification requirements for submission of the new RAPS format.
For information regarding the new RAPS error codes and/or record layout, contact CSSC Operations at 1.877.534.2772 or by e-mail at firstname.lastname@example.org.