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Risk Adjustment Advisor
December 2015: Looking to 2016
As December winds down we can't help but be excited for the new year. For our retainer clients: we hope that you have enjoyed the gift sent out earlier this month. Also, if you haven't responded to the annual service-coordination email, please contact us as soon as possible to make these arrangements.
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Risk Adjustment Today:
Matt Zimmerman
Risk Adjustment Consultant
Payment Year (PY) 2013 Overpayment Recovery

On December 17th CMS released the memo titled "Payment Year (PY) 2013 Overpayment Recovery". In the memo CMS reaffirms the overpayment regulations contained in 42 CFR ยง422.326, where all Medicare Advantage (MA) organizations are required to return overpayments. This memo pertains to risk adjustment data submitted with dates of service in calendar year 2012. This data was used to generate payments in calendar year 2013. The memo reminds all MA plans of the process to address any outstanding deletion/redaction data by January 8, 2016. Continue Reading

Richard Schamp, MD
Progress Notes:
Dear Friends,
As 2015 draws to a close, we find our attention drawn to holidays, family gatherings, and end-of-year mayhem.  It's also a time of reflection and thinking about what is to come in the next year.  Mother used to tell me that "anticipation is half the fun", so  I'd like to mention some plans we have for the PACE community in 2016. 
First, look to hear more about changes in our website in a new client-only section.  Clients will be able to log-in for access to expanded information about our services for them, reference tools,
training materials, and more.  With further development, we will be able to provide reports and other direct services securely through this portal. 
Next, though the implementation to ICD-10 is behind us, there is continued need to look up or cross-reference diagnosis codes.  We have previously told you about, which contains the full sets of both ICD-9 and ICD-10 with the mappings between them and also all mappings to HCCs and RxHCCs.  Though this website is already available on your smartphone browser (or any computer browser), we are working to make this tool available with its own native app for iPhone and Android devices in 2016.
Third, we are close to realizing a long-held hope of mine, which is to make advance analytics tools available to the PACE community.  Large health insurance plans have had access to such tools for years, but we are proud to be committed to bringing robust technology regarding your encounter data, RAPS and diagnosis codes directly to the point of care.  The impact such analytics can have on efficiencies and completeness in your risk adjustment processes will gratify at multiple levels.  You will be hearing more about this in the coming weeks.
The staff at Capstone join me in thanking our clients for a successful year in achieving progress toward your goals.  It is truly our pleasure to serve you and help in some way to support the care you give to an important, yet vulnerable, segment of our society.  We count it an honor.  As Christmastide begins, we wish you the best of holidays and hope for the new year.
Joyfully yours,

Richard O. Schamp, MD
The A,B,Ds of Medicare:
Mike Brett, MD
DSM 5 Terminology

As I have discussed before, DSM 5 was released last year and contains some new concepts. There is no longer a category of Substance Abuse or Substance Dependence. (The term "substance" referring to alcohol, cannabis, opioids - prescribed or illicit - and benzodiazepines to name a few). Now, in its place, DSM 5 combines abuse and dependence into one category known as "Substance Use Disorder." While both abuse and dependence have unique definable characteristics, my sense was that DSM 5 wished to see these disorders on a continuum and, to thereby help eliminate the question of when abuse become dependence - which at times can be difficult to discern.

Documentation Dispatch: 
Sequela due to CVA or Cerebrovascular Disease

According to Medicare guidelines "sequela (late effects), is the residual effect after an acute phase of an illness or injury. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to previous injury." When documenting, the late effect has to be linked to the cause in order to code correctly. For example, right dominant hemiplegia due to CVA, I69.351. Continue Reading

Within the next couple weeks, we will be sending out an email to all of our clients explaining how to register for the new Client Portal on the Capstone website. Anyone from your location is encouraged to register, as it will contain useful information for understanding our services and reports, gaining a better understanding of risk adjustment, and accessing helpful links for improving compliance and risk scores.

This is just one way we hope to improve our commitment to serving your program in 2016.


We hope you have a safe and blessed New Year.


Neta Kessler 
Operations Manager
Capstone Performance Systems
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