Risk Adjustment Advisor
Issue 6: Looking Ahead to 2015
In our last issue we gave thanks for all of our wonderful clients. Not only do we appreciate their trust in our knowledge and abilities but they also trust that we will work hard to evolve our services to meet their changing needs. As the year winds down we take stock of not just our victories but also where we can make changes and improve in the coming  year. Whether it is through a new service, added level of analysis, or whether it is through improving our customer service focus to ensure someone is always available for any question or need, we push ourselves to meet any challenge your program may have.
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Risk Adjustment Today:


Hello Everyone,

On Wednesday 12/03/14 the MAPD helpdesk issued this notice.

This brief communication from CMS reiterates the importance of the HIPAA privacy and security regulations. Losing CMS system access along with a possible fine for violating the CMS Security policy would be devastating. It's simply not worth the risk.

This cautionary notice is a reminder to all plans that the use of PII/PHI is of great concern to CMS. Taking time now to review existing policy and procedure surrounding PII and PHI is an important part of understanding any risks at your Plan. Does your existing procedure define how secure emails are to be sent? An examination of how participants HIC#s and other sensitive information is sent and received at your organization is warranted.

Consider conducting a risk analysis to determine your level of compliance. This along with additional training and reinforcement will ensure compliance at your Plan with the use of PII/PHI.


December 2014


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Progress Notes:

Greetings from St. Louis.  As 2014 draws to a close, most of us look for ways to celebrate, usually within some faith tradition (perhaps excepting New Year's Eve).  The large majority of organizations that we associate with have a faith-based heritage, and so you might understand why  I especially enjoy the Advent season, followed by Christmastide.  Whether you celebrate these seasons according to a  traditional emphasis that centers on the Incarnation of God in Jesus Christ, or with festivities honoring God's miracles with Hanukkah, or with other traditions, a common theme is that God intervenes in human lives to do what they cannot do themselves.


It is in this spirit that we honor each of our clients and all organizations that carry out a parallel mission - to intervene in the lives of your participants,  who are generally the most vulnerable in our society, providing services to them and their families.  You do for them what they cannot do for themselves, and we are proud to partner with each of you in that mission.


Gift giving is common in this season also, and we at Capstone have a small gift for your providers and others that need to look up diagnosis codes often.  We have developed an mobile app that allows look-up of any ICD-9 diagnosis code via the official description of the code and also designates if the code is associated within any HCCs (in the V22 PACE risk adjustment payment model) or RxHCCs (for Part D).  The app will also list all diagnosis codes associated with any HCC or RxHCC.  This app is available without charge at  No log-in is required and it will run on any smartphone through the phone's web browser.  (When opening the app on a phone, please be patient, as it will take a few moments to load all the tables into the browser.  It is best to leave it open in the background if you find it useful.)  This version is 1.0 and will be updated for ICD-10 in 2015, so we'll welcome any feedback or suggestions.  This will also run on any computer, and is best with FireFox or Chrome browsers.


Merry Christmas!

On Target:  LIFE St Francis, NJ


"We honor the leadership, providers and coding staff at LIFE St. Francis in Trenton, NJ.  One of our first clients, the team has been exemplary in following recommendations and optimizing the resources Capstone makes available to them.   Angie Winiarski and the providers lead the way in being complete and accurate in documentation and coding." -Dr R. Schamp, CEO

Great Job, LIFE St Francis!

Documentation Dispatch: 
Coding for Pathologic Fractures

 Often times a participant will have previous or existing vertebral compression fractures or have had a minor fall resulting in a hip or wrist fracture. It is important to assess whether these are traumatic fractures, or pathologic. Pathological fractures occur when bone weakened by an underlying, pre-existing disease or condition breaks. The hallmark of pathologic fractures is when the bone fractures spontaneously or with minimal trauma. Several underlying disorders can weaken the bone and result in a pathologic fracture. A common disorder prevalent in the elderly that could cause this is osteoporosis.

When diagnosing and documenting for pathologic fractures, it is important to note the presence of osteoporosis, or other underlying condition, and note the fracture as being pathologic. The fact that the patient has a bone-weakening condition does not mean the fracture is pathologic and thus it must be documented as such. Supporting documentation for this diagnosis must be must be aimed at treating the residual effects of the fracture, i.e. pain, and not osteoporosis alone. However, treatment for the osteoporosis should also be included in the documentation.


We want to hear from you!

If you are one of our  retainer clients, in the next few days the leadership team at your program will receive a scheduling email for our 'Annual Service-Coordination Call'. During this call we go over our efforts during 2014 and investigate ways to make improvements in 2015. We will also discuss possible dates for training visits. If you are planning to participate, please respond as soon as possible, as time slots fill up fast. 



We wish you the very happiest of holiday seasons! 


Best Regards,   

Neta Kessler MS
Operations Manager
Capstone Performance Systems

Next Month: 'New Services'
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