On April 1, the Centers for Medicare & Medicaid Services (CMS) released the Final Announcement outlining changes to the HCC Payment model for Medicare Advantage Plans and PACE Programs for Payment Year 2020. The HCC model used to calculate risk scores for PACE will change from the version used since 2012 (Version 21) to the 2017 model known as Version 22.
Tag Archives: "Medicare Risk Adjustment"
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…
Diagnosing and Coding for Chronic Kidney Disease
Diagnosing and Coding for Chronic Kidney Disease
By: Angie Hlad, CRN-C, Risk Adjustment and Coding Coordinator
Chronic kidney disease (CKD) is the gradual, and often permanent, loss of kidney function. It is a progressive condition that can result in significant morbidity and mortality. The condition is common in the elderly , and impacts the PACE population. Nearly 50% of individuals over 70 years old meet the definition of CKD…
Medicare Part D Readiness Review – Preparation and Compliance
Medicare Part D Readiness Review – Preparation and Compliance
Submitted by: Matt Zimmerman
The importance of developing and maintaining a Medicare Part D Compliance Program, focused on adhering to PACE guidelines, cannot be overemphasized. Plans that have a strong internal auditing and monitoring program in place are reassured they are within compliance regulations. Plans on the other side of the spectrum are plagued with the stress and worry that…
Neta Kessler hired as Project Specialist at Capstone Performance Systems
Neta Kessler hired as Project Specialist at Capstone Performance Systems
BOULDER, Colo.–November 21, 2013– Dr. Richard Schamp, CEO of Capstone Performance Systems, announced that Neta Kessler has been hired as Project Specialist. Capstone Performance Systems works with Programs of All-inclusive Care for the Elderly (PACE) and similar organizations to demystify Medicare risk adjustment methodologies and to enhance performance, compliance and revenue. PACE organizations provide community-based, comprehensive care to frail seniors; they…
Diabetes Mellitus Coding Guidlines
Diabetes Mellitus Coding Guidelines
Sommer Huseman, RN, Risk Adjustment and Coding Specialist
Diabetes mellitus is a condition that results when the body is unable to produce enough insulin or properly use the insulin that it does produce. The disease of diabetes is present in a significant number of patients and consumes more than $100 million in health care resources in the United States. Therefore, it is important that the guidelines for coding diabetes mellitus are understood. Correct coding of diabetes is…
CMS Requirements for Monitoring and Auditing
CMS Requirements for Monitoring and Auditing
Submitted by: Matt Zimmerman
The importance of developing and maintaining a robust Internal Monitoring and Auditing Program focused on adhering to PACE guidelines cannot be underestimated. Plans that have a strong program in place are assured in knowing that they are within the regulations and experiencing the reassurance that compliance adherence affords. Plans on the other side of the spectrum are plagued with the stress and worry that comes with either not knowing if they…
Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 2
Correcting 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…
Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) – Part 1
Correcting 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…
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…