Retrospective Chart Review

The current risk adjustment methodology for PACE involves specific deadlines for diagnosis data submission to impact future Medicare payments. For example, diagnoses from the previous year that are submitted by the first Friday in March and are accepted by CMS will usually be used in the next model run to generate the risk score for participants in July.

Programs are allowed retrospective chart reviews to identify missed diagnoses to be submitted by either the interim or final deadline. (CMS allows 13 months after the close of a period for late diagnosis submissions.) Capstone has staff with the knowledge, skill, and experience in identifying documented, but unsubmitted, diagnoses that may be captured for submission.

Capstone will provide remote professional diagnosis coding services for outpatient primary care assessments and other relevant encounters for Medicare-enrolled PACE participants according to Official ICD-9 Coding Guidelines (and ICD-10, when applicable). In addition, Capstone will review consultant reports for diagnosis codes. The primary goal of this review is to identify missed diagnoses codes that were not submitted to CMS in the previous year thus allowing for submission of identified codes by the final deadline.

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