Risk Adjustment Advisor
Issue 4: New Team Additions
Here we grow again!
The past year Capstone has seen an incredible amount of growth and success. With not only the expansion of services but also with the addition of new team members, we are continuing to make great strides in improving our family of PACE programs.
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Risk Adjustment Today:
Acceptable Specialty Types and EMR


Ensuring correct usage of Acceptable Physician Specialty Types in Risk Adjustment data

Validating all RAPS data, ensuring accurate and complete submission, is a routine process throughout the calendar year. However, a good year-end compliance initiative is to ensure all accepted RAPS data was submitted to CMS for only "Acceptable Physician Specialty Types" as required by CMS.

With the ever expanding role of the Electronic Health Record it's far too easy to submit incorrect data to CMS. Using the list of "Acceptable Physician Specialty Types" as a guide to monitor your RAPS data is a great way to ensure compliance. The list is available on the CSSC Operations website under Risk Adjustment processing systems/References.

In reviewing this list there are certain specialties that are not acceptable types for risk adjustment data and they are excluded from this list. For instance, type 59-Ambulance and type 47- independent lab provider types are not in this list and therefore not acceptable sources for risk adjustment data. The best practice here is to ensure your electronic medical record is allowing only acceptable physician specialty types to flow through for risk adjustment data submissions. The compliance and monitoring exercise here is to ensure that previously accepted RAPS data does not contain unacceptable specialty types.

The overall goal is to ensure that in the event of an audit there is acceptable source documentation on file for all accepted RAPS data and only from acceptable physician specialty types. If it is discovered that unacceptable data was submitted it must be redacted before the next sweep of RAPS data in March 2015.

October 2014


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Progress Notes:

We are looking forward to the NPA Conference in San Diego this month and the opportunity to be face-to-face with friends that we've made among our clients (and some that we haven't met yet).  We'll be well-represented and will be featuring some new services, so please come by our exhibit booth.


This month, I highlight three changes in our staffing that position us for continued growth and progress in helping clients meet the challenges around documentation improvement, risk adjustment and compliance.  First, we are pleased to welcome Dr. Mike Brett as our inaugural Chief Medical Officer as he joins Capstone full time.  Dr. Brett served for ten years as Medical Director for LIFE Programs at LIFE Lutheran Services, a PACE organization serving multiple counties in western Pennsylvania.  A graduate cum laude from Temple medical school, he is a board-certified internist and geriatrician.  We are certain his energy, skills and experience will mean continued excellence to our clients and fresh developments in our trainings and consultative support.

Next, our staff heartily welcomed the addition of Ms. Lynn McLafferty as administrative assistant in our home office.  Lynn has many years of experience and is taking on increasing responsibilities to keep mission-critical operations going smoothly. 

With the growth of our documentation improvement and coding department, we've watched Angie Hlad, CRN-C grow along with those challenges and she is now promoted to Manager.  Many of you have met Angie, and have benefitted from her professionalism and helpful demeanor.  She'll be working with our other nurse coders to ensure continued high-quality service and customer care.

Remember to come by booth #6 and see us in San Diego.


   On Target: Cherokee Elder Care                



 "On a recent visit to Cherokee Elder Care it was great to see  such a united team addressing the CMS requirements from Risk Adjustment to Part D. The team was very interested in reviewing and further developing their existing Medicare work plan. Since the visit this Plan has taken a very active role in improving their internal monitoring and auditing program. These efforts will 'pay back' this Plan with improved compliance confidence and financial consistency."-Matt Zimmerman, Risk Adjustment Consultant 

Great Job,                                   
    Cherokee Elder Care!                          
Documentation Dispatch: CHF vs. Diastolic Dysfunction


When diagnosing and documented for diastolic dysfunction in the absence of heart failure it is important that you are not paralleling the two diagnoses.

Diastolic dysfunction is considered a risk factor for heart failure.  When diastolic dysfunction is not explicitly documented with heart failure, it should not be coded as heart failure.  For example:  Diastolic dysfunction by itself indexes to ICD-9 code 429.9; CHF indexes to ICD-9 code 428.0. 

While diastolic dysfunction often leads to CHF, it should not be used interchangeably with it.   Appropriate documentation would be to include both diagnoses.  For example: CHF due to diastolic dysfunction. 

Diastolic dysfunction can be listed and coded by itself. However, it can be also listed as evidence of Stage B CHF which according to AHA and ACC guidelines (and those adopted by the NPA Primary Care Committee's Model Practice on CHF) on its own; however, it should be listed as "Stage B Congestive Heart Failure secondary to diastolic dysfunction."

Product Spotlight:

This month we are highlighting all of our products at the NPA conference. Stop by booth #6 to learn more about which services would be right for your program.



If you are attending the NPA Conference this year you will the get opportunity to meet one of our new team members, Dr George Brett. If you have not RSVP'd to the CareKinesis and Capstone dinner or our other events, please do so as soon as possible. Also, remember to check your conference bag when you arrive for an exciting game-the first 150 winners will receive a prize. When you come by our booth we will also have exciting giveaways, including our NEW APP that allows a user to look up ICD-9 diagnosis codes and associated HCCs!


See you there! 


Best Regards,   

Neta Kessler MS
Operations Manager
Capstone Performance Systems

Next Month: 'Looking Forward to 2015'
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