Risk Adjustment Advisor
Issue 7: New for 2015

We hope that your new year is off to a great start. Here at Capstone we have been busy with our 'Annual Service-Coordination Calls' to our retainer clients. A change from last year is that our new Chief Medical Officer, Dr George Brett, has been able to attend many of these calls and has enjoyed getting better acquainted with many of our clients. He is also the newest contributor to our newsletter-we hope you enjoy his section: 'The ABDs of Medicare'!
(cont'd below)
January 2015
Stay Connected:
Progress Notes:

Over the past few months in working with our clients, we have had multiple reminders of the importance of completeness and accuracy requirements for data submission to CMS and State agencies.  I want to focus my message this month on the need for PACE organizations (PO) to be alert to both internal and external processes regarding Risk Adjustment (RAPS) data reporting.  Part of your agreement with CMS is an attestation that you will

"Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis must be coded according to International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Guidelines for Coding and Reporting."


Along with this, CMS expects that:

  • each PO will specify and implement procedures to ensure that only data from acceptable sources are submitted. 

  • POs will conduct internal audits and/or hire external auditors to determine that diagnosis codes submitted meet risk adjustment submission requirements

  • POs will delete submitted ICD-9 codes that are incorrect as soon as possible

  • POs are responsible for all data submissions and their content, regardless of using third party vendors.

 We strongly recommend an annual review of your RAPS and Part D policies and procedures and QAPI plan to be sure that you are performing sufficient internal auditing and monitoring such that your compliance officer has no doubts about the accuracy and completeness of the data submitted.


Besides the regulatory requirements for PACE organizations, the OIG work plan for 2105 also places emphasis on data quality and specifically indicates the OIG will review medical record documentation to ensure that it supports the diagnoses submitted to CMS for use in CMS's risk-score calculations and determine whether the diagnoses submitted complied with Federal requirements.


We encourage PACE Organizations to make data integrity (completeness, accuracy and security) a high priority for your compliance and QAPI programs for 2015.


The ABD's of Medicare


 Several of our clients have expressed concern about the Medicare Part D reconciliation. When the annual reconciliation time for Medicare Part D occurred, they owed CMS a substantial amount of money. Was this bad?

Actually, in a perverse way, this is a good situation. Medicare Part D is a prospective payment. CMS "loans" you the money, but wants to see how that money was spent, which you do by submitting to CMS what are called Prescription Drug Event (PDEs). If, however, at the end of the year by good control of your pharmacy expenditures (a topic for a later time), your program didn't spend all that was received from your "bid," then that money is owed back to CMS.

That's the bad news. The good news is, that with application of the "Risk Corridors," only a portion of that money is returned. In fact, the first 5% of the total expenditures under the total bid amount, you keep completely. With further savings, even more is kept but some is owed back to CMS.

Therefore, by proper accrual for the bid amount minus what was spent, sending Medicare a large check is a happy time. This is because your program got to keep a significant part of your Medicare D bid that was never technically yours to begin with.

Ah, now if only you could use those savings for a trip to the Caribbean.

George "Mike" Brett MD


On Target:  Senior CommUnity Care of Colorado



    "Senior Community Care of Colorado       is exemplary in documentation and  
    coding. The providers and staff exhibit 
    professionalism and also compassion 
and kindness towards others. Working
    with them has been and continues to
    be a rewarding experience." -A. Hlad,
    Coding Manager


Great Job, Senior CommUnity Care of Colorado!

Documentation Dispatch: 
Coding for Osteoarthritis

One of the most common conditions diagnosed and treated within the PACE population is osteoarthritis. This is many times coded incorrectly. There are several codes under the Osteoarthrosis and allied disorders category. Here are some tips for correctly diagnosing this condition.

Osteoarthritis (OA) is categorized into two main categories with two additional subcategories; localized and generalized osteoarthritis and primary and secondary osteoarthritis. The difference between localized and generalized is essentially straightforward but primary and secondary have specific criteria. Primary OA or idiopathic OA is OA with no known cause and is generally considered to be age related.

Secondary OA is due to some identifiable initiating factor. Generally these factors are obesity, trauma, congenital malformations, metabolic or circulatory bone diseases, etc. Properly coding secondary OA requires two codes, one for the OA and the other to identify the causative injury, disorder or disease.

If there is no designation of the type of osteoarthritis, usually one of two codes is used; 715.90 or 715.89. For example:

Osteoarthritis of multiple sites - 715.89.  

Osteoarthritis - 715.90.

If the documentation states osteoarthritis of one site but is not identified as primary or secondary, it is coded 715.3X, per ICD-9 guidelines. 


This is always an exciting time of year for us. We get to hear how excited our clients are with their improving risk scores or listen as they confidently tell us how our trainings have  helped increase their compliance understanding. We also get to listen to their current and upcoming challenges and what their newest goals are. 


In response to these challenges, we are working diligently to create new training webinars for ICD10 as well as advanced Part D training packages and reporting options. Keep a lookout in upcoming newsletters for additional details!


Best Regards,   

Neta Kessler MS
Operations Manager
Capstone Performance Systems

Next Month:  'Showing a Little Heart'
Capstone Performance Systems |