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Risk Adjustment Advisor
August 2015: Time is Running Out!
ICD-10 is only 42 days away, are you ready? We have been excited to receive a lot of great feedback on our ICD-10 educational webinar series. If you haven't had the chance to attend, it's not too late! You can view previous sessions, and register for upcoming sessions, on our website!
The third session, 'Coding for CHF, HTN, CAD, & Angina' is
scheduled for today, Wednesday, August 19th at 3:00pm EST.  

Richard Schamp, MD
Progress Notes:
Last Chance to Correct RAPS for PY 2012
CMS notified all PACE Organizations (POs) and other risk-adjusted entities yesterday of their plans for RADV (Risk Adjustment Data Validation) audits for Payment Year 2012.  Organizations will be notified on Sept 14 if selected for an audit.  (If anyone wants to know details of the pain involved in a RADV audit, ask me...)
RADV audits are conducted to enforce compliance regarding the submission of complete and accurate diagnosis data in the Risk Adjustment Processing System (RAPS).  Typically, incomplete or inaccurate RAPS data leads to overpayment to plans, but it can also cause underpayment.  POs must report and return overpayments (usually caused by incorrect or unsupported diagnosis codes in RAPS, but also related to PDE, DIR, LIS, or other payments) as required by the Affordable Care Act.  In a spirit of cooperation, CMS is allowing plans to redact incorrect information from 2011 Dates of Service prior to the audit, which greatly reduces the potential extrapolation costs of incorrect or unsupported diagnosis codes.  In our work with many PACE plans, we know that mistakes happen and inaccurate and unsupported codes are submitted.  (Continue Reading)
The ABD's of Medicare:
New Enrollee Designation, HPMS Memo 8/14/2015

Mike Brett, MD


When a participant first becomes eligible for Medicare, there are no ICD9 codes on which to base a payment using the Risk Adjustment model. The reason being, that this year's payment is based on ICD9 codes submitted from last year, and a newly enrolled participant to Medicare has no data on which to base payment. Therefore, the participant is assigned to the "New Enrollee" RA Factor Type Code. He/she will remain in that category until they have 12 months of Medicare Part B experience during the data collection period. "New Enrollee" designation uses demographic information only to calculate a risk score. The demographic coefficients are a bit higher compared to a participant, with the same demographics, who is eligible for the Risk Adjustment Model; however, the "New Enrollee" risk score results in a much lower risk score than the average participant. A typical new enrollee risk score is 1.20 compared to the average in PACE of 2.50. (Continue Reading)
Angie Hlad, CRN-C
RA & Coding Dept Manager
Documentation Dispatch:
ICD-10 Overview
Diabetic coding in ICD-10 has changed significantly from ICD-9. The requirement for documenting the type of diabetes and linking it to any complications still exist. However, in ICD-10, there are very few diabetic codes that require an additional code for the manifestation. Those that require an additional code are diabetes with CKD and diabetes with a foot ulcer.
ICD-9 and ICD-10 guidelines for coding diabetes require the provider to document diabetes and the complication, ensuring the documentation states a relationship between the diabetes and the complication. For example, diabetes with kidney complications, specifically CKD, would be documented: Diabetes with nephropathy due to diabetes, CKD stage 3, and this would be coded as E11.22 and N18.3. Here, the additional code for the stage of CKD would be required, N18.3. (Continue Reading)
Product Spotlight: Mock RADV Audit 

Instead of a low risk score, did your program receive one that is much higher than expected? Are you kept up at night wondering if your program will stand up to CMS scrutiny?

Let us put your mind at ease with our mock Risk Adjustment Data Valuation (RADV) Audit service. Using the same methodology as CMS, we will look through your files and determine your potential risks and guide you through a plan to correct them. You can learn more or contact us today for more information.

Hopefully this month's mid-year reconciliation provided assurance of your program's success. Some won't be so lucky, and are realizing the impact even a fraction of a point will mean to their bottom line. Whether it's low payments, RAPS deadlines, ICD-10 implementation, facing an audit, or your program is new and you are just trying to get your bearings, Capstone can help. Our leadership brings over 50 years combined PACE experience to provide the best advice, strategies, and solutions to guide you through whatever you are facing.  

Neta Kessler
Operations Manager
Capstone Performance Systems
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