By Debbie Ploschnitznig, CRN-C
Degenerative disc disease (DDD) describes the symptoms of pain and possibly radiating weakness or numbness stemming from a degenerated disc in the spine. Simply put, degenerative disc disease occurs when an intervertebral disc loses its integrity, eventually causing pain. The condition is most often caused by age-related deterioration of the spine. (more…)
By Richard Schamp, MD, CEO
PACE organizations are accustomed to receiving final reconciliation of the prior year’s Part C and Part D payments in July. This reconciliation is reflected in the Monthly Membership Report (MMR) and typically includes a positive true-up payment, especially if retrospective reviews were done in timely fashion. However, this year the PY2016 reconciliation is delayed until October, as CMS communicated during their April CMS Risk Adjustment EDS & RAPS User Group presentation. The delay is due to…
We have been describing multiple aspects of risk adjustment compliance in our newsletters, along with helpful tips on documentation and coding. CMS requires PACE, Medicare Advantage and similar organizations to submit all relevant diagnosis codes at least once yearly. A “relevant” code is one that impacts Part C or Part D payment. Failure to submit all relevant codes is an important compliance issue. To help our clients with the dual challenges…
By Richard Schamp, MD
CEO, Capstone Performance Systems
Definitions
Nephropathy refers to any disease of the kidney. In common clinical parlance, the term is modified by an etiology referring to one of over a dozen types, such as analgesic nephropathy, gouty nephropathy or most commonly, diabetic nephropathy. Chronic Kidney Disease (CKD) is defined by GFR (Glomerular Filtration Rate) less than 60 ml/min per 1.73 m2 and/or kidney damage for three or more months. The presence of albuminuria is most commonly used to…
It is unlikely that a clinician would overlook properly documenting a patient with neurologic quadriplegia resulting from a cervical spine injury. However, somewhat less obvious might be functional quadriplegia that results from a patient’s severe weakness. This condition is the inability to move due to disability or frailty caused by another medical condition but not from direct physical injury or damage to the brain or spinal cord (ACP Hospitalist Coding…
By Jan Deyber, CRN-C, and Tiffany Brookshire, BSN, CRN-C
We often see inconsistency in medical records regarding diagnoses as current or historical. Documenting “history of” when referencing a patient’s past medical background is a longstanding practice. Providers may intend a “present perfect” tense – a condition that started in the past and continues in the present. However, in the world of diagnosis coding, “history of” indicates a past (or past perfect) tense; in other words, a condition that no longer…
by Richard Schamp, MD, Chief Executive Officer
When documenting in the medical record, providers should take care to capture their thoughts and findings as completely as possible. Best practice is to document the patient encounter at the time, or shortly afterwards. Inevitably, situations require some changes in the medical record, of which four types are recognized. (more…)
by Katina Yablinsky, CRN-C
In October 2016, there was an update to the ICD-10 coding guidelines that allows a coder more flexibility in assigning certain codes. Previously, the guidelines stipulated that if two conditions are related to each other, the provider needs to document their relationship for them to be coded as such. (more…)
On Target recognizes a client who is showing process improvement from putting Capstone’s processes and advice into action.
Pain points
ICD-10 was the tipping point. CMS’s implementation of the new edition of the coding system was the point of no return for Senior Total Life Care (STLC), a PACE organization serving 175 participants in a rural area less than 20 miles outside of Charlotte, North Carolina. (more…)
by Richard Schamp, M.D., C.M.D., C.H.C.Q.M., Chief Executive Officer
Several times in 2016, my comments in this column have emphasized elements related to corporate compliance with regulations and rules governing documentation and coding. As 2016 comes to a close, I wish to share two key messages from a recent compliance and auditing conference.
Listening to presentations from several prominent healthcare lawyers, I was reminded of the priority (which we have mentioned repeatedly here) for all healthcare organizations, especially health plans, to have…
by Angie Hlad, CRN-C
When documenting ulcers, it is important to clarify if the ulcer is a pressure or non-pressure ulcer. When a provider only documents the stage of the ulcer, such as “stage 2 ulcer, left heel”, it is does not provide enough information for the coder to determine the proper code assignment. Once the provider makes the determination of chronic non-pressure or pressure ulcer, it should be documented as such. The documentation for these two types of ulcers…
by Christy Wills, CPC, CRC
Fracture coding has become increasingly more specific in ICD-10. As a result of this specificity, providers must document, in some form, whether the fracture is traumatic or pathologic (non-traumatic). A traumatic fracture is caused by some type of accident, fall, or other kind of force. For example, a traumatic fracture can occur after a car accident or when a person is struck with a heavy object. A pathologic, or non-traumatic fracture, is the break of a…
by Tiffany Brookshire, RN, BSN, CRN-C
The implementation of ICD-10 has increased the specificity for many, if not all, disease processes. One such condition is Major Depressive Disorder, a commonly diagnosed condition in the PACE participant population. The correct documentation of MDD will result in a more specific and risk adjusted code, while incomplete documentation will result in an unspecified code that does not map to an HCC.
Read More by Dr. George W. Brett
The multi-year freeze on changes to ICD codes ended with the launch of ICD-10 last October. We are all up to speed with ICD-10, right? Good, because on October 1, 2016, the 2017 edition became effective. Providers, coders and billers need to be knowledgeable with these changes as there is no grace period. Using codes that are deleted or changed will impact claims and risk adjustment.
Read More While attending HealthCon 2016 this month, sponsored by the American Academy of Professional Coders, I was struck by several facts and trends and want to pass these on to our PACE community friends. Most of these have to do with compliance issues related to documentation, coding and payment. As mentioned previously, I’ve selected compliance our dominant theme in 2016, and much of what I heard at HealthCon reinforces this.
CMS notified all PACE Organizations (POs) and other risk-adjusted entities yesterday of their plans for RADV (Risk Adjustment Data Validation) audits for Payment Year 2012. Organizations will be notified on Sept 14 if selected for an audit. (If anyone wants to know details of the pain involved in a RADV audit, ask me…)
RADV audits are conducted to enforce…
When a participant first becomes eligible for Medicare, there are no ICD9 codes on which to base a payment using the Risk Adjustment model. The reason being, that this year’s payment is based on ICD9 codes submitted from last year, and a newly enrolled participant to Medicare has no data on which to base payment. Therefore, the participant is assigned to the “New Enrollee” RA Factor Type Code. He/she will remain in that category until they have 12 months of Medicare Part…
With the most recent sweep of RAPS data completed, now is the time to re-validate the accuracy of calendar year 2014 RAPS data. Ensuring that proper medical record documentation is on file and readily available is a large part of validating RAPS data accuracy. While the focus is most certainly on internal documentation, external provider documentation should not be overlooked. Considering that some RAPS data submitted is unique to external providers only emphasizes the importance of proper medical record…
One of the best things you can do for ICD-10 is be as prepared as possible. There are many free ICD-10 web trainings available and Capstone will be providing its own ICD-10 webinar series beginning July 23, 2015. Please check your email regarding information to register for these webinars making sure to check junk and spam mail.
Some of the changes from ICD-9 to ICD-10:
Specificity- ICD-10 will provide more specificity, thus increasing the code structure from ICD-9’s 3 to 5…
Please click here to register for this event.
With ICD-10 only a couple months away, Capstone understands the pressure that PACE programs are under. We have been working diligently to create training and technological strategies to ensure our clients are fully supported. (more…)
On June 24th CMS issued a memo regarding the inclusion of PACE in the 2016 Medicare Plan Finder website and the ‘Medicare & You’ handbook.
This memo urgently requests plan users to validate the accuracy of specific contact data in the Health Plan Management System (HPMS). The primary fields to review/update are in the memo and this data will be used by CMS to update the website and handbook. This is a tremendous marketing opportunity not previously afforded to…
Even though the first day of summer is a few weeks away, we have been enjoying an eventful and thrilling spring! Not only have we been busy sponsoring the the NPA Spring Policy Forum, the North Carolina PACE Association Conference, and the American Academy of Home Care Medicine Conference, we have also gone through another exciting ‘growth spurt’. (more…)
COPD is a condition that is often times incorrectly documented. COPD can be referred to as an irreversible airway obstruction associated with chronic bronchitis and/or emphysema. Asthma is defined as a reversible airway obstruction, which means it can be treated to remove the airway obstruction.
If COPD (496) is documented by itself, the coder can justly assign code 496. Asthma documented by itself would be assigned ICD-9 code 493.90. However, when COPD (496) and asthma (493.90) are documented together, careful…
For several years, but especially over the past year, we have heard increasing discussions and commentary about the evolution of American healthcare toward the concept of value. Value is defined in several ways, but commonly is understood in terms of outcomes relative to costs. Simply reducing costs without attention to outcomes is risky and may not produce desired results. CMS has promoted the well-known “triple aim” with three value vectors of patient…
On June 1st CMS issued a memo titled “Payment Year 2014 Risk Adjustment Attestation.” This memo reaffirms the plan requirement to complete an annual attestation of risk adjustment data. The attestation is for payment year 2014, so plans will be attesting to the accuracy of the data submitted with a 2013 date of service, which made up payment year 2014. The attestation is…
Chief Executive Officer
Professional Experience
PACE programs don’t often face the possibility of a participant receiving a renal transplant. However, most Executive Directors and Medical Directors worry that, should that situation arise, that the cost would be prohibitive and that their program could never absorb the financial burden. Fortunately, that is not the case.
Your dialysis participants don’t use the Version 21 HCC model that is used to calculate risk scores for your other participants. Instead they…
On February 27th CMS released a memo called “Annual Verification of Parent Organization and Legal Entity Name”. This memo requested Plans to review the accuracy of their company’s parent organization and legal entity name in the Health Plan Management System (HPMS). The memo requested Plans to report any necessary corrections by March 16th.
For PACE plans a change in the Parent organization or legal name is fairly infrequent. However, this memo should serve as a compliance reminder to maintain…
When documenting depression, it is important to document completely and accurately in order for the most appropriate and specific code to be assigned. The correct diagnosis and ICD-9 code may be the difference between a diagnosis that maps to an HCC and one that does not. For example, ICD-9 code 311 (depressive disorder, NEC) does not map to an HCC, but 296.XX (major depression) maps to HCC 58.
There are not DSM IV criteria for “depression” and “major” depression; only…
As we mentioned in previous missives, compliance with CMS regulations for data management is a big theme this year. CMS provided two HPMS memos recently that are relevant to PACE organizations that wish to demonstrate compliance in an important way. The first memo on Feb 18 refers to the requirement for PACE Organizations to return overpayments to CMS in a timely fashion (defined by the Affordable Care Act as within 60 days after the overpayment is identified).
Most overpayments are…
Sometimes, we providers use terms that are very specific and covey a tremendous amount of meaning. Two of those terms are “Ischemic Cardiomyopathy” and “Hypertensive Cardiomyopathy.” When I hear those terms I get a sense that there is dysfunction of the heart – “Heart Failure” – caused by coronary artery disease or hypertension.
If you use those terms, thinking that you have documented a specific type of Heart Failure and that…
As you know the Mid-Year sweep of RAPS data is hastily approaching. The upcoming deadline is Friday, 03/06/15. This deadline pertains to RAPS data from calendar year 2014, which is the basis of payment in calendar year 2015. After the deadline CMS will recalculate current 2015 payments based on any new information received. With this deadline looming, now is a great time to ensure all of your ICD-9 code data has been submitted and accepted by CMS.
Taking steps now…
Some believe they got lucky when the ICD-10 implementation deadline was extended to 2015 because they had procrastinated on learning it. All indications are that the deadline will not be extended a third time, so further hoping is probably not a good strategy. To make the transition manageable in your program we recommend scheduling some time every month to work on it, starting as soon as possible.
While coding guidelines remain largely the same, ICD-10 is a very different coding…
Osteoporosis is a disease of the bones common to the population we treat. Osteoporosis can affect both men and women and woman can lose up to 20% of their bone mass in the years after menopause.
There are two categories of Osteoporosis: primary and secondary. Primary osteoporosis includes postmenopausal, senile and idiopathic. Secondary osteoporosis is caused by various medical conditions including chronic kidney disease, rheumatoid arthritis and hyperthyroidism.
Coding for osteoporosis is not difficult if the documentation indicates which type of…
St. Louis, MO, November 7, 2014 – Capstone Performance Systems CEO Richard Schamp, M.D., C.M.D., C.H.C.Q.M, named George W. Brett, M.D., as Capstone Performance Systems’ Chief Medical Officer. Capstone provides expert Medicare risk adjustment services to Programs of All Inclusive Care for the Elderly (PACE) and similar healthcare organizations to ensure proper reimbursement and optimal utilization of services and funds.
‘Risk Adjustment Advisor, #8 February 2015
‘Risk Adjustment Advisor’, #7 January 2015
‘Risk Adjustment Advisor’, #6 December 2014
‘Risk Adjustment Advisor’, #5 November 2014: Correction Notice
‘Risk Adjustment Advisor, #5, November 2014
‘Risk Adjustment Advisor’, #4, October 2014
‘Risk Adjustment Advisor’, #3, September 2014
‘Risk Adjustment Advisor’, #2, August 2014
‘Risk Adjustment Advisor’, #1, July 2014
Saint Louis, MO July 1, 2014 – Dr. Richard Schamp, CEO of Capstone Performance Systems, announced several staffing changes and additions at Capstone Performance Systems. Capstone is a consulting firm dedicated to working with Programs of All-inclusive Care for the Elderly (PACE) and similar organizations to optimize Medicare risk adjustment methodologies and to enhance performance, compliance and revenue. PACE organizations provide community-based, comprehensive care to frail seniors and functionally disabled adults. PACE is funded by Medicare and Medicaid with local…
Clinical Documentation Improvement in PACE
By: Dr. Richard Schamp, CEO
Clinical documentation is at the core of every healthcare encounter. Therefore it should be complete, precise, and reflect the diagnoses as well as the scope of care and services provided. Assuring consistency in provider documentation that is accurate, specific, legible and timely represents a challenge for many organizations.
Providers (doctors, nurse practitioners, therapists and others) are trained in clinical documentation, but often…
Documentation and Coding for Chronic Heart Failure in PACE
By: Sommer Huseman, RN, Risk Adjustment and Coding Specialist
Participants often enter PACE with limited understanding of their conditions and some have been treated for CHF without explicit awareness. This treatment may be camouflaged by clinical setting – overlapping treatment of hypertension or renal conditions or a tendency for clinicians to downplay the diagnosis by referring to “pump problems” or other descriptions. The astute practitioner will have a high index of suspicion…
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…
Diagnosing and Coding for Chronic Kidney Disease
By: Angie Hlad, CRN-C, Risk Adjustment and Coding Coordinator
Chronic kidney disease (CKD) is the gradual, and often permanent, loss of kidney function. It is a progressive condition that can result in significant morbidity and mortality. The condition is common in the elderly , and impacts the PACE population. Nearly 50% of individuals over 70 years old meet the definition of CKD…
Medicare Part D Readiness Review – Preparation and Compliance
Submitted by: Matt Zimmerman
The importance of developing and maintaining a Medicare Part D Compliance Program, focused on adhering to PACE guidelines, cannot be overemphasized. Plans that have a strong internal auditing and monitoring program in place are reassured they are within compliance regulations. Plans on the other side of the spectrum are plagued with the stress and worry that…
Neta Kessler hired as Project Specialist at Capstone Performance Systems
BOULDER, Colo.–November 21, 2013– Dr. Richard Schamp, CEO of Capstone Performance Systems, announced that Neta Kessler has been hired as Project Specialist. Capstone Performance Systems works with Programs of All-inclusive Care for the Elderly (PACE) and similar organizations to demystify Medicare risk adjustment methodologies and to enhance performance, compliance and revenue. PACE organizations provide community-based, comprehensive care to frail seniors; they…
Documenting and Coding for Morbid Obesity- HCC 22
By: Dr. Richard Schamp, MD
Frequently we receive questions about documenting and coding for levels of obesity. This is because Morbid Obesity triggers an HCC and thus provides payment, which is appropriate, due to the extra costs involved in the care of the condition. We would like to provide some clarification around this issue.
Morbid Obesity HCC 22
Several ICD-9 codes currently map to HCC 22 in the CMS-HCC v21 (as well as RxHCC 21). …
Diabetes Mellitus Coding Guidelines
Sommer Huseman, RN, Risk Adjustment and Coding Specialist
Diabetes mellitus is a condition that results when the body is unable to produce enough insulin or properly use the insulin that it does produce. The disease of diabetes is present in a significant number of patients and consumes more than $100 million in health care resources in the United States. Therefore, it is important that the guidelines for coding diabetes mellitus are understood. Correct coding of diabetes is…
Put MEAT in Documentation for Healthy Audits
Submitted by: Angie Hlad, CRN-C, Risk Adjustment and Coding Coordinator
Complete and accurate documentation is the key for impacting quality, safety, efficacy, and data integrity. Additionally, complete and accurate documentation helps safeguard against payment recovery from Medicare in an audit situation.
Medicare wants to ensure payments to PACE organizations match the expected costs of care. In order to accomplish this, CMS scrutinizes health plans with both random and targeted audits for validity of diagnoses submitted. …
CMS Requirements for Monitoring and Auditing
Submitted by: Matt Zimmerman
The importance of developing and maintaining a robust Internal Monitoring and Auditing Program focused on adhering to PACE guidelines cannot be underestimated. Plans that have a strong program in place are assured in knowing that they are within the regulations and experiencing the reassurance that compliance adherence affords. Plans on the other side of the spectrum are plagued with the stress and worry that comes with either not knowing if they…
Correcting 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…
Correcting 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.
BOULDER, Colo.–August 21, 2013– 
Dr. Richard Schamp, CEO of Capstone Performance Systems, announced that Angie Hlad is now credentialed by the American Association of Clinical Coders and Auditors (AACCA) as a Certified Registered Nurse (RN) Coder. Angie has worked for Capstone as a Risk Adjustment and Coding Coordinator since 2012. She is responsible for chart reviews and audits, client education, and working with clients to maximize reimbursement.
“We are pleased at…
BOULDER, Colo.–June 28, 2013–Dr. Richard Schamp, CEO of Capstone Performance Systems, announced that Sommer Huseman has been hired as Risk Adjustment and Coding Specialist. Capstone Performance Systems works with Programs of All-inclusive Care for the Elderly (PACE) organizations to optimize Medicare risk adjustment processes and enhance performance, compliance and revenue. PACE organizations are sponsored by Medicare and Medicaid and provide community-based, comprehensive care to frail seniors.
Sommers’s responsibilities…
Written by: Dr. Richard Schamp, CEO
The Centers for Medicare and Medicaid Services (CMS) perform risk adjustment data validation audits on patients’ medical records. Risk adjustment data validation (RADV) is the process of verifying diagnosis codes submitted for payment are supported by medical record documentation. The purpose is to ensure risk adjusted payment integrity and accuracy. CMS has announced its intention to increase auditing activity consistent with an emphasis to reduce payment errors.
Signs your plan may be at risk for…
BOULDER, Colo.–June 24, 2013–Dr. Richard Schamp, CEO of Capstone Performance Systems, announced that Matthew Zimmerman has been hired as a Risk Adjustment Consultant. Capstone Performance Systems works with Programs of All-inclusive Care for the Elderly (PACE) organizations to optimize Medicare risk adjustment processes and enhance performance, compliance and revenue. PACE organizations are sponsored by Medicare and Medicaid and provide community-based, comprehensive care to frail seniors.
Zimmerman brings a well-developed understanding of all aspects of enrollment and other health plan management functions…
BOULDER, Colo.–May 8th, 2013–The National PACE Association (NPA), which represents Programs of All-inclusive Care for the Elderly (PACE) nationwide, has made an agreement with Capstone Performance Systems (Capstone) to provide assistance to NPA members. Specifically, Capstone will provide training and resources for documentation and coding procedures that will be integral to the full implementation of CMS Encounter Data Reporting System (EDRS) for PACE organizations in 2014.
Regulated by Centers for Medicare and Medicaid Services and state Medicaid agencies, PACE organizations…
Capstone Performance System is expanding service to our clients by developing a knowledge base for your reference in regard to Risk Adjustment and related topics. We invite clients to share this link with all interested parties in your organization (but not with outside parties). Anyone in your organization can obtain log-in credentials. While much of the information we post here is available elsewhere, some is proprietary. Our main goal is to give you a single source for reference.
Resources will…
The links below will allow you to download commonly asked for reference files that are provided here for your convenience.
BOULDER, Colo.–October 23, 2012– Dr. Richard Schamp, CEO of Capstone Performance Systems, announced that Angie Hlad has been hired as Risk Adjustment and Coding Coordinator. Capstone Performance Systems works with Programs of All-inclusive Care for the Elderly (PACE) organizations to demystify Medicare risk adjustment and enhance performance, compliance and revenue. PACE organizations provide community-based, comprehensive care to frail seniors; they are sponsored by Medicare and Medicaid.
Angie’s responsibilities include chart reviews and audits, staff education, and working with the staff to…
BOULDER, Colo. –August 27, 2012–David Reyes, principal of Altitude Edge and partner for Capstone Performance Systems, announced that Dr. Richard Schamp has been selected chief executive officer. Capstone Performance Systems works with Programs of All-inclusive Care for the Elderly (PACE) organizations to demystify Medicare Risk Adjustment and enhance performance, compliance and revenue. PACE organizations provide community-based, comprehensive care to frail seniors; they are sponsored by Medicare and Medicaid.
According to Reyes, “Dr. Schamp comes to this role with years of…
BOULDER, Colo. –August 15, 2012– Altitude Edge announces the creation of Capstone Performance Systems, a team devoted solely to the increasing need for accurate Medicare risk adjustment services.
Altitude Edge has been providing risk adjustment services for several years, to Programs of All-inclusive Care for the Elderly (PACE) and similar health care organizations. PACE and similar organizations provide critical care services to seniors so they may remain safely at home.
Altitude Edge created Capstone Performance Systems to devote a complete team…
