Risk Adjustment Advisor
Issue 3: NPA Excitement!
It's hard to believe that fall is just around the corner. By now you are probably aware that the 2014 annual NPA conference will be held in beautiful San Diego, California. This is a special year because NPA is celebrating the 20th year of PACE, and Capstone Performance Systems is very excited to be sponsoring the conference audio and visual needs for this special occasion. We hope this will give several opportunities for everyone to become familiar with our new brand, as well as our expanded and enhanced services. We will also be co-hosting, along with our sister company CareKinesis, a special pace appreciation event 'Dinner with a View', as well as a cocktail social, welcoming new and developing PACE programs. Watch your email for upcoming details!

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Risk Adjustment Today:
CMS Memo- "2014, 2015, 2016 Payment Run Notice"

With this recent CMS memo, Payment Run Notice, plans now have an updated Risk Adjustment data sweep schedule. Using this information, Plans can make certain their RAPS data submissions to CMS are in line with CMS expectations. Submitting all data ahead of the sweep deadlines is extremely important for risk adjustment data integrity and meeting these deadlines will help assure an accurate risk adjustment payment from CMS.


September 2014


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Progress Notes:

One of the far-reaching outcomes of the ever-evolving rules on Medicare risk adjustment is an emphasis on compliance, and especially on recovery of improper payments.   According to a Final Rule, published by CMS in the Federal Register on  May 23, 2014, Medicare Part C plans can expect more of is audits. It is not known yet how prevalent these audits will be for PACE plans, but the mood for eliminating excess payments is high.

For example, CMS will be introducing a Recovery Audit Contractor (RAC) for Part C (these already exist for Parts A, B and D).  RAC auditors use medical record review and automated edit, to identify improper payments. Also, beginning in 2015, the OIG will be doing Risk Adjustment Data Validation (RADV) audits.  We can only assume these will be similar to current CMS RADV methodology, but are likely to be more targeted. 

Capstone is helping our clients to prepare for audits in several ways.

  • Some have asked us to do the coding for all their encounters, which helps their risk adjustment data to be complete and accurate. One medical director found this service so helpful that he described it as "my restful sleep insurance".  

  • We have also begun providing Mock RADV Audits, following current CMS methodology.  These audits will uncover vulnerabilities and assist programs to develop corrective measures. 

  • Our chart audit service in our Risk Adjustment Bundles provides clients data validation and is a boon for documentation improvement.

We urge clients to give attention to their internal auditing and monitoring processes, especially around diagnosis coding and data submission.



Contact us today to learn more.  

Piedmont Health SeniorCare at Pittsboro
  On Target: Piedmont Health SeniorCare


  "Piedmont's documentation is second to none.     
  Every diagnosis has a goal, and plan, with 
  additional supporting documentation.  
  continue to be consistent and thorough 
  throughout their chart records." -A Hlad, Risk  
  Adjustment and Coding Coordinator


       Keep up the good work,          
    Piedmont Health SeniorCare!      
Documentation Dispatch: 
Documentation and Coding for Neuropathy 
It is a common mistake to be too general in regards to documenting diagnoses.  Accurately documenting a diagnosis is critical in properly assigning an ICD-9 code and could potentially effect payment if documented and coded incorrectly.  Neuropathy is a perfect example.  Documenting only Neuropathy would index to code 355.9 which does not map to an HCC; when documenting Peripheral Neuropathy, it would index to ICD-9 code 356.9, which maps to HCC 75.  It is also important to remember if neuropathy is due to diabetes mellitus, the relationship between the two diagnoses must be documented.  Neuropathy due to diabetes indexes to ICD-9 code 357.2.

Product Spotlight:


Risk Adjustment data is gathered by PACE Organizations from many sources and submitted. Ensuring accuracy and completeness is critical for improving and maintaining your plan's risk adjustment score, besides being required for basic compliance principles.

The Risk Adjustment Data Integrity (RADI) review offered by Capstone is a useful tool for supporting your internal monitoring and auditing work plan. The RADI review will help determine the overall accuracy of your risk adjustment data over a predetermined time period.

Utilizing your existing accepted RAPS data the RADI process identifies and separates out information into four groups. These groups are where suspect coding or limited documentation support may lie. Reviewing these groups will provide any Plan with a foundation for internal monitoring of RAPS data and additional assurances that data submitted to CMS is accurate.


Contact us today for more information and schedule a free evaluation to determine if a Risk Adjustment Data Integrity (RADI) Analysis is right for your program.  

Capstone has been growing in many new and exciting ways this year. We can't wait to celebrate these changes, with our current and future clients, at the upcoming conference. Be sure to check your welcome bag when you arrive! The first 550 entrants will have the chance to participate in a game that will give the first 120 winners a fun prize. Also, stop by our booth to get a chance at the grand prize, a new Samsung Galaxy Tab


The Capstone staff is looking forward to the opportunity to meet new faces, as well as catch up with longtime associates. See you there!


Best Regards,   

Neta Kessler MS
Operations Manager
Capstone Performance Systems

Next Month: A New Addition to Our Team!
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