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Latest Articles, News Releases and Newsletters

New Enrollee Designation, HPMS Memo 8/14/2015

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…

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Importance of External Provider Documentation to validate RAPS data

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…

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ICD-10 Overview

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…

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Capstone’s ICD-10 Webinar Series

 

Please click here to register for this event.

PACE is Now Included in the Medicare Plan Finder

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…

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Documenting COPD & Asthma

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…

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Value Based Healthcare

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…

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Risk Adjustment Attestation Due this month

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…

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Key Leadership Curriculum Vitae

RICHARD O. SCHAMP, MD (Abridged)

Chief Executive Officer

Professional Experience

  • Clinical Professor, Department of Family and Community Medicine and Clinical Professor, Internal Medicine, Division of Geriatrics (Secondary), Saint Louis University School of Medicine, St. Louis, MO 63104 (present)
  • Private Family Medicine Practice, Agape Family Health Center P.C., DuBois, PA 15801 (1983-1998)
  • Medical Director, Contract Nursing Services (Home Health), DuBois, PA (1985-1988)
  • Medical Director, Personal Health Options, Inc., DuBois, PA (1986-1990)
  • Physician Advisor, Clearfield County Area Agency on Aging (1987-1998)
  • Faculty Physician, Family Medicine of St….

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Renal Transplantation

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…

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Annual Verification of Parent Organization and Legal Entity Name

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…

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Documenting and coding: Depression vs. Major depression

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…

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Progress Notes: CMS Compliance for Data Management

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…

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Tips for Coding Heart Failure

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…

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Importance of Monitoring RAPS Data

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…

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Strategies to prepare for ICD-10

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…

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Documenting Osteoporosis

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…

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Capstone Performance Systems Names George W. Brett, M.D., Chief Medical Officer

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. 

George W. Brett M.D.

George W. Brett M.D.Systems’…

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Staff Expands in Breadth and Depth

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…

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Clinical Documentation Improvement in PACE

Capstone LogoClinical 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…

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Documentation and Coding for Chronic Heart Failure in PACE

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…

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Enrollee Risk Assessment Code in RAPS Starts Jan 1, 2014

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…

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Diagnosing and Coding for Chronic Kidney Disease

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…

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Medicare Part D Readiness Review – Preparation and Compliance

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…

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Neta Kessler hired as Project Specialist at Capstone Performance Systems

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…

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Documenting and Coding for Morbid Obesity – HCC 22

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). …

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Diabetes Mellitus Coding Guidlines

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…

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Put MEAT in Documentation for Healthy Audits

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.  …

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CMS Requirements for Monitoring and Auditing

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…

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

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…

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

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…

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Angie Hlad receives credentials from the American Association of Clinical Coders and Auditors

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…

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Sommer Huseman joins Capstone Performance Systems

Capstone Logo

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…

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Risk Adjustment Data Validation (RADV) Guidelines for Medical Record Documentation

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…

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Capstone Performance Systems hires Matthew Zimmerman

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…

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Capstone Performance Systems selected to provide training for National PACE Association members

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…

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Welcome to the Capstone Performance Systems Knowledge Center

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…

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ICD-9
in Knowledge Center | tagged:

The links below will allow you to download commonly asked for reference files that are provided here for your convenience.

 

Angie Hlad joins Capstone Performance Systems

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…

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Capstone Performance Systems names Richard Schamp, M.D., as CEO

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…

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Altitude Edge forms new business, Capstone Performance Systems, for dedicated Medicare risk adjustment

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…

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