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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 cluster must be deleted from the system before the correct cluster is added. For this reason, data correction is at least a two-step process.

Each diagnosis cluster is stored separately as a unique cluster associated with a beneficiary’s HIC number. If a diagnosis was submitted in error and needs to be corrected, the original diagnosis cluster must be resubmitted with a delete indicator in the appropriate field.  When a delete record is received, CMS maintains the original diagnosis cluster on file and adds a delete indicator to it and the date of the deletion.

PACE organizations submit deletions within a file, batch, or record containing previously submitted risk adjustment data.

 Steps for Deleting a Diagnosis Cluster

Before deleting an error, verify that the diagnosis cluster appears on the RAPS Return File. Only diagnosis clusters accepted by RAPS and stored in the RAPS database may be deleted.

There are two methods for deleting diagnosis clusters:

Method 1

  1. Submit RAPS format using normal submission process with appropriate HIC number included.
  2. Enter information in the diagnosis cluster fields exactly as it appeared in the original submission.
  3. In field 9.3 enter a “D” for delete.
  4. Enter the appropriate information in all other records to ensure the submission file is complete.
  5. Transmit the file to FERAS. (See www.csscoperations.com for details.)

Method 2

  1. Create a file using the Direct Data Entry (DDE) screens available through FERAS at Palmetto (detailed information about the DDE process is located in Section 4.20 of the 2008 RAPS Participant Guide).
  2. Enter information exactly as it appeared in the original submission.
  3. In the DDE “CCC” record screen, hit the down arrow key and select “D.”
  4. Proceed with entering all appropriate information.
  5. Upload the file created in DDE to FERAS at Palmetto.

 Additional Considerations

  • If the PACE organization submits corrected data, they must submit the appropriate deletion record. That is, if the correct diagnosis cluster is submitted, the erroneous diagnosis cluster cannot be ignored.
  • If a correction applies to the same beneficiary as the deletion, the correction may be included in the same “CCC” record as the deletion.
  • If only one of several clusters within the CCC record requires modification, do not resubmit all other associated clusters. If clusters are resubmitted exactly the same without the delete indicator, the plans will generate a duplicate cluster error.
  • If the corrected diagnosis cluster belongs to a different participant than the deleted diagnosis cluster, the correct diagnosis cluster may be submitted in the same file as the deletion.
  • MA organizations should not delete a diagnosis code or record repeatedly on the same day and on the same record. MA organizations should implement a process to ensure that only one instance of a specific diagnosis cluster (either add or delete) is submitted on a given day.
  • These processes should be incorporated into the PACE Organization’s internal auditing and monitoring policies and procedures and also detailed in the fraud waste and abuse policy.

 

*The information presented here complies with accepted coding practices and guidelines as defined in the ICD-9-CM coding book. It is the responsibility of the healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM code(s) according to the official coding  guidelines.

*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.

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 on best knowledge, information, and belief) (42 C.F.R. § 422.504(l))
  • This creates a duty to, at a minimum, “put in place an information collection and reporting system reasonably designed to yield accurate information,” including ordinarily conducting “sample audits and spot checks . . . to verify whether [the system] is yielding accurate information” (64 F.R. 61893, 61900 (Nov. 15, 1999))

CMS expects its contractors, including POs, to self-police and self-report regarding compliance with regulations.  This concept was reinforced in a HPMS Memo issued late February 2013 on the subject of “CMS consideration of self-disclosure by plan sponsors of non-compliant conduct in the determination of compliance actions”:

              Since 2006, CMS has consistently advised Medicare contractors to report voluntarily to CMS any instances of program non-compliance that they discover on their own. As CMS staff have stated in numerous presentations to industry, we look more favorably on Medicare contractors when we learn of their non-compliance from them rather than through other means… CMS believes that self-reporting can be seen as evidence of an effective compliance program, indicating that while some non-compliance has occurred, the contractor has capable management and oversight in place exercising effective control over the organization.

          Self-reporting is one of several factors… that CMS considers when assessing compliance. Also, the absence of self-reporting may qualify as an aggravating factor, as CMS may issue a higher level of compliance notice when a Medicare contractor fails to self-report non-compliant conduct.

So, besides assuring compliance and effective QI processes, there is a positive side to doing the right things in regard to self-disclosure and error corrections.

Standards of Data Accuracy Require Correcting Errors.

Some examples of regulatory language underscore the requirements for error correction.

  1. PACE plans must filter risk adjustment data to ensure diagnosis submissions comply with CMS’s MA “guiding principles” (e.g., face-to-face encounter, in accordance with diagnosis coding guidelines, acceptable provider type and physician specialty) (CMS 2008 MA Participant Guide § 4.11)
  2. PACE plans must “ensure the accuracy and integrity of risk adjustment data submitted to CMS . . . [and] if upon conducting an internal review of submitted diagnosis codes, the plan sponsor determines that any . . .codes have been erroneously submitted, the plan sponsor is responsible for deleting the submitted . . . codes as soon as possible” (Medicare Managed Care Manual § 40)
  3. PACE organizations are required to delete records when an erroneous diagnosis cluster has been accepted by CMS (CMS 2008 MA Participant Guide § 4.16)

 

What Kinds of RAPS Errors Need Correction?

There are occasions where plans will need to delete diagnosis clusters. Here are some reasons for deleting the clusters.

  1. Diagnosis clusters submitted erroneously (e.g., data from an interim bill was submitted for hospital inpatient, type of bill 112 / 113. When TOB 114 has been received.), therefore, plans should correct the previously submitted claim with the corrected diagnosis clusters.
  2. Incorrect HIC number used for submission on a beneficiary’s claims
  3. An error in a diagnosis cluster field (i.e., “Provider Type,” “Dates of Service,” “Diagnosis Code”), such as when it is discovered upon review that a diagnosis code is not supported by the documentation, for example.  Another common situation is when ineligible diagnosis codes are submitted in error through a faulty electronic extraction process from EMR notes.

 

PACE Organizations must have established processes in place for internal auditing and monitoring that help them to detect errors.  These procedures are often described in the Part D Fraud, Waste and Abuse policy and are a routine part of corporate compliance functions.

 

Next time – How to correct errors in RAPS.

 

References:

-2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide

-CMS Memorandum of  February 27, 2013 on CMS consideration of self-disclosure by plan sponsors of          non-compliant conduct in the determination of compliance actions

-Electronic Code of Federal Regulations (e-CFR) —  42 C.F.R. § 422.504(l)

-Federal Register – 64 FR 61893 – Publication of the OIG’s Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plans

-Medicare Managed Care Manual, Chapter 7 – Risk Adjustment § 40

 

*The information presented here complies with accepted coding practices and guidelines as defined in the ICD-9-CM coding book. It is the responsibility of the healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM code(s) according to the official coding  guidelines.

*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.

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 the high level of competence and experience Angie has demonstrated to assist our clients in their documentation and coding efforts, “  stated Dr. Schamp. “ Her unique combination of clinical nursing experience and mastery of coding knowledge positions her well in the field of coding, documentation review, Medicare compliance and revenue integrity for healthcare organizations.”

The AACCA certification process provides recognition for Angie’s ability to demonstrate her substantial understanding, knowledge and skills specific to Point-of-Care Coding and revenue integrity. The AACCA is the only organization in the United States that provides testing and certification in compliant coding and conducting chart reviews.

Sommer Huseman joins Capstone Performance Systems
posted by: in Press Releases

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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 include chart reviews and audits, staff education, and working with staff to maximize reimbursement. She has over 17 years of experience in the medical field including critical care, acute care, long term care and PACE.  Sommer’s understanding of CMS compliance, PACE documentation guidelines and ICD/ HCC coding and reimbursement will make her an asset to the organization.

“Our clients have benefitted from our documentation improvement reviews and training to assist them in both compliance and revenue,” Dr. Schamp said. “Sommer brings solid PACE experience and a strong clinical background to bolster these services.”

Sommer is from Grindstone, Pennsylvania. She is a Registered Nurse and received her BSN from California University of Pennsylvania.

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 a RADV:

  • Large change in year-over-year risk scores – CMS will focus on plans with big increases in score to ensure it is correct
  • Very few delete records – if you are not doing deletes, you are reviewing your own submissions for accuracy and correcting errors
  • Other corrective actions – has your plan been reviewed for something else? It may increase your likelihood of audit as CMS sees you as a risk.

At Capstone Performance Systems we have some specific documentation guidelines to follow to promote compliance with CMS data validation.

  • Medical record documentation must be legible.
  • For risk adjustment data validation purposes, CMS will only consider medical record documentation from a face-to-face encounter (between a patient and physician/provider). [Note: CMS does not accept initials and a date on a lab report as adequate documentation. They also do not accept a copy of a note in the file where lab results were mailed to a patient. The condition or findings must be discussed and notated in the patient face-to-face encounter for CMS to accept this as appropriate documentation. Superbills or encounter forms and problem lists are also unacceptable types of medical record documentation to validate an ICD-9 CM code.]
  • Physician’s signature and their credentials must be included on each patient encounter, the following is acceptable: Mary C. Smith, MD or MCS, MD.  [Note: credentials must be either next to the provider’s signature or pre-printed with the provider’s name on the practice’s stationery.]
  • Electronic Signature – requires authentication by the responsible provider (for example, but not limited to “Approved by”; “Signed by”; or “Electronically signed by”. They must also be password protected and used exclusively by the individual provider.) 
  • Signature Stamp – Stamped signatures are no longer acceptable for provider documentation effective January 1, 2009.
  • Typed Signature – is unacceptable unless it is authenticated by the physician/provider. 
  • Patient’s name must appear on every page of the medical record and all entries/encounters must be dated.
  • Records must be coded in accordance with the ICD-9-CM Guidelines for Coding and Reporting. Medical record documentation must support the code selected and substantiate that the proper coding guidelines were followed. Documentation must support that condition was addressed such as status of condition, lab values, PE, symptoms, education.  Ordering labs and medications does not validate the diagnosis.
  • Code all documented conditions that coexist at the time of the visit, and require or affect patient care treatment or management.  Do not code conditions that were previously treated and no longer exist.  However, history codes may be used if the historical condition or family history has an impact on current care or influences treatment. Do not document a diagnosis as “history of” for a condition that is acute or chronic still requiring management or treatment.
  • Chronic conditions treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). Address chronic conditions at least every 6 months.  Code all documented conditions that coexist at the time of the visit and require or affect patient treatment or management.  Even if the note states, “doing well with diabetic diet or continues to do home blood sugar monitoring,” CMS considers this notation as meeting their criteria.
  • Sign the medical record and make all notations timely. [Note: CMS expects records to be documented at the time of the visit.]  Addendums are acceptable in certain circumstances such as the following: Patient has visit for a mole removal. The pathology report is received several days after the office visit and confirms malignant melanoma. The physician reviews the findings, initials the report, and documents in the record the results and notification to the patient.  Since the removal of the mole was done during the office visit, the new code (for example,172.9) should be submitted with that date of service.
  • Unacceptable types of diagnoses.  “Probable”, “suspected”, “questionable”, “rule out” or “working” diagnoses cannot be reported to CMS as valid diagnoses by a physician or in the outpatient hospital setting.
  • Document specificity of condition.  Specify conditions as chronic, major, recurrent and type of condition such as chronic renal insufficiency, major depression, chronic hepatitis C, if the condition is chronic, major, or recurrent.
  • Linking diagnosis with manifestations.  When conditions are related, link them together in the documentation, for example, diabetes with peripheral vascular disease.  When linking conditions, include documentation to support both conditions.  Use additional diagnosis codes to identify manifestation.  If both conditions are not validated, it cannot be coded as linked.
  • Use V codes when appropriate.  Document health status conditions in notes (amputation status, transplant status, dialysis, HIV status, and artificial opening such as colostomy and ileostomy).

For more information about RADV please contact us.

 

*The information presented here complies with accepted coding practices and guidelines as defined in the ICD-9-CM coding book. It is the responsibility of the healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM code(s) according to the official coding  guidelines.

*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.

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 that impact Medicare revenues. He also has extensive experience working with Medicare Part D management.  In his new position, Zimmerman will help Capstone clients improve their processes to avoid mistakes in RAPS (request for anticipated payment) data management. Zimmerman will play a key role in the evolving analytic services to support clients through meaningful analyses of their data.

“Matthew is an expert in all aspects of risk adjustment business processes, with skills honed in the trenches of working in a PACE environment for 13 years,” Dr. Schamp said. “He adds both depth and breadth to our team and is a rich source of experience and knowledge that will directly benefit our clients.”

Zimmerman is from Denver, Colo. He holds a double major in psychology and sociology from Purdue University.

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 deliver a community-based and comprehensive model of care for frail seniors who desire to live at home. Capstone works with PACE organizations to support Medicare risk adjustment and enhance performance, compliance and revenue. The training offered by Capstone for NPA members will include discipline-specific webinars to support the PACE interdisciplinary team members that utilize existing procedure codes.  Additionally, Capstone will develop a set of resources to support the NPA members’ use of procedure coding and enhanced model Superbills that will be available on the NPA website.  EDRS requires procedure codes to quantify the services provided to PACE participants and has been partially implemented in 2013 for standard health care claims.   Compliance with the full EDRS implementation requires reporting procedures for all encounters provided in the PACE centers or by PACE staff.

“Capstone is pleased to work alongside our colleagues in the PACE community to develop resources that will assist with compliance and implementation of the challenging encounter data reporting requirements,” commented Richard Schamp, M.D., CEO of Capstone Performance Systems.

 

 

Welcome to the Capstone Performance Systems Knowledge Center
posted by: in 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 be available in relevant categories, such as:

  • CMS risk adjustment reference materials
  • Teaching presentations
  • FAQs regarding risk adjustment topics
  • Condition-specific monographs for documentation helps
  • General and specific ICD-9 coding guidelines and examples
  • Resources for ICD-10 training
  • Resources for CPT coding for Encounter Data Reporting
  • Links to outside resources
  • Risk Adjustment Data Validation Audits

As new material is absorbed into the Knowledge Center, we will notify you. The Knowledge Center is to serve you, our clients, so we encourage you to comment and make suggestions for resources. You can also contact us by email (info@capstoneperformancesystems.com).

We’re just getting started, but feel free to explore the Knowledge Center today.

Best Wishes,

Your Capstone Team

ICD-9
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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
posted by: in Press Releases

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 maximize reimbursement. Before accepting her position at Capstone, Angie worked with SeniorLIFE, a PACE program in Pennsylvania. Angie’s background includes a mix of clinical and administrative experience as well as documentation, coding and reimbursement experience that will strengthen the services Capstone provides.

“I am pleased to have recruited an experienced nurse who understands the subtleties of the PACE model of care and the risk-adjusted payment system,” Dr. Schamp said. “Angie is skilled at understanding the documentation and coding requirements that support optimal compliance and payments for PACE organization.”

Angie is from Brownsville, Pennsylvania. She is a Registered Nurse and received her BSN from Waynesburg University in 2002.

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