Capstone Performance Systems' new Client Success System, an exclusive feature
of our Core Services Retainer Plan, is designed to identify gaps in operations that
impact risk adjustment compliance and revenue -- and then to help close those gaps. Director Matt Zimmerman leads the CSS team, which includes Malissa Bolish, CRN-C, RN supervisor and client success liaison (left), and Katina Yablinsky, CRN-C, client success consultant. 

Risk Adjustment Advisor: March - April 2018
Richard Schamp, MD Chief Executive Officer

It's hard to believe spring is upon us already, at least according to the calendar. We had the opportunity to see some of you at conferences/meetings in Michigan and DC last month, and look forward to seeing our North Carolina clients and friends soon.

In the PACE world, the HOS-M survey will be hitting participants mailboxes any day. Read below for more information about this important questionnaire and ideas for encouraging accurate completion. Also in
 this issue, we further discuss the importance of clinical documentation competency and provide relevant information on coding Substance Use Disorders.

Richard Schamp, MD
Chief Executive Officer 

Provider Education and Support 

By Richard Schamp, MD

In our last edition, I mentioned the burgeoning new competency for physicians and other clinical providers: clinical documentation excellence. Let's delve further into some specifics around the kinds of competence required in a risk-adjusted payment model. CMS has a process to verify that diagnosis codes reported that are relevant for payments in the HCC (Hierarchical Condition Category) model are both correct and supported by the medical record documentation. This process is referred to as Risk Adjustment Data Validation (RADV). While most PACE organizations have not yet experienced a RADV audit, they must comply with all the requirements of documentation and coding, and assume that they will eventually face an audit. 
It's That Time of Year: The HOS-M Survey is Coming

By George "Mike" Brett, MD
Senior Vice President of Consulting and
Chief Medical Officer

In addition to demographic information and HCCs, a portion of a PACE participant's risk score is derived from the Frailty Factor (FF). Eligible participants in PACE have the FF added to their risk score because the CMS-HCC Model uses diagnoses codes which consistently under-predict the cost of care for the frail elderly. This happens because predicting cost based on diagnosis codes alone can't account for the added cost that results from older adults' functional impairment as a consequence of the diagnosis.

Documentation and Coding for Substance Use Disorders 

By Amanda Piern, CRC
Risk Adjustment Coder

ICD-10-CM significantly expanded the codes available for substance use disorders (SUDs). To properly code for these disorders, diagnosis documentation should include the type of use disorder.  The ICD-10 index includes the following use disorders:
  • Alcohol use
  • Amphetamine-type substance use
  • Cannabis use
  • Cocaine use
  • Hallucinogen use
  • Inhalant use
  • Opioid use
  • Phencyclidine use
  • Sedative
  • Hypnotic
  • Anxiolytic use
  • Stimulant use (other) (unknown)
  • Substance use (other) (unknown)
  In each case, the provider must document the severity of the disorder as mild, moderate or severe. The Diagnostic and Statistical Manual 5th Edition (DSM5) provides guidelines to determine if the disorder exists and its severity.

Dr. George "Mike" Brett Named
Senior Vice President of Consulting Services

George "Mike" Brett, MD, has been named Senior Vice President of Consulting Services for Capstone Performance Systems. Dr. Brett, who retains his title of Chief Medical Officer for Capstone, will oversee Capstone's new Consulting Services team. Capstone Performance Systems provides expert Medicare risk adjustment services to Programs of All-Inclusive Care for the Elderly (PACE) and similar healthcare organizations to ensure proper reimbursement and optimal utilization of services and funds.

Capstone Welcomes New Staff Members

Capstone Performance Systems is pleased to welcome three new staff members. Dana McDermott, RN, CPC, joins our Coding and Auditing team as a risk adjustment and coding specialist. Dana has a BSN from Carlow College in Pittsburgh and a nursing diploma from the Conemaugh School of Nursing in Johnstown, Penn. She previously served as a senior fraud analyst at Highmark, Inc., and also has experience in research compliance and protocols.

We have also added two new risk adjustment coders to the team. Emily Cramer, CPC, has a diploma in medical billing/coding diploma from the Education and Technology Institute in Greensburg, Penn. She previously served as a financial director/billing manager for a private practice and as a medical biller/coder at the Neurological Institute of Western Pennsylvania. Kiera Williams, LPN, CPC, CHCCS, CMCS, has a certificate in practical nursing from Daytona State College in Florida. Kiera previously worked as a psychiatric coding auditor at Aviacode; an HCC specialist at Medical Audit Services, Inc.; and as a Medicare risk adjustment liaison/MRA manager at Metropolitan Health Networks/Humana.

Capstone on the Road 

We were pleased to be able to see so many of our clients and friends at the recent National PACE Association Spring Forum in Washington, DC, and the PACE Association of Michigan Meet & Greet in Lansing. Though it seems some of our staff are always on the road, it is so beneficial for us to connect with people in a setting outside of their PACE facilities.

Next up for us is North Carolina. Capstone Performance Systems is proud to be a sponsor of the North Carolina PACE Association's Fifth Annual Conference April 12-13 in Durham. If you're planning to attend, stop by and visit us at Table 24 in the exhibit hall.


Calling All PACE Clients:
We want your feedback!

As Capstone Performance Services continues to grow, it is important that we continue meet our clients' expectations and provide the outstanding service for which we are known. To assist us, we have posted an online survey for our PACE clients. If your PACE organization/center is a current Capstone client and you have not yet completed the survey, we invite you to do so now. All respondents who complete the survey and provide their contact information will be entered into a drawing for a $250 Amazon gift card for their center. The survey can be found here and will be open until Friday, April 13.

Clinical Documentation Excellence (CDE) Bulletin 

Capstone Performance System's Clinical Documentation Excellence (CDE) Bulletin, is a monthly e-bulletin with topics relevant to Primary Care Providers. Information typically includes clinical background, diagnosis tips, documentation requirements and ICD-10 coding guidance. Each month, the CDE Bulletin focuses on  a topic that is timely or requested by our clients. Recent issues explored Documentation and Coding for Skin Ulcers and Diagnosing, Documenting & Coding COPD . To suggest a topic, contact Richard Schamp, MD . Past issues are available on .

For more information on our services and how we can assist your organization, email or visit

© Capstone Performance Systems 2017. All rights reserved.

Richard Schamp, MD, Publisher/Executive Editor
Carla Davenport, MBA, MS, Editor

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