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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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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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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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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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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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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On June 1^st 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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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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On February 27^th 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 16^th.

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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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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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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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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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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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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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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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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