Category Archives: "Articles"

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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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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