Category Archives: "Articles"

Diabetes Coding in ICD-10

Diabetic coding in ICD-10 has changed significantly from ICD-9. The requirement for documenting the type of diabetes and linking it to any complications still exist. However, in ICD-10, there are very few diabetic codes that require an additional code for the manifestation. Those that do require an additional code are diabetes with CKD and diabetes with a foot ulcer.

ICD-9 and ICD-10 guidelines for coding diabetes require the provider to document diabetes and the complication, ensuring the documentation states a…

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Last Chance to Correct RAPS for PY 2012

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…

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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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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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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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