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Risk Adjustment Advisor
Issue 9: You Don't Need Luck
While this month everyone else's thoughts may have been on the 'Luck of the Irish', Dr Schamp has been busy in his office, compiling data for the newest analysis of Capstone's impact on our client programs. Did you know that Capstone's retainer clients average a payment increase of over $400 per member, per month?--Now that is quite a pot of gold! Did you also know the average payment increase grows over time so that the longer a client is with us, the greater the financial impact? This is because Capstone is committed to always improving our training sessions, reports, and coding services to build stronger results for your program. This kind of success is not luck; it's due to improved completeness and accuracy of documentation and coding that we help programs achieve.
(cont'd below)
Risk Adjustment Today:
Importance of Monitoring RAPS Data


On February 27th CMS released a memo called "Annual Verification of Parent Organization and Legal Entity Name". This memo requested Plans to review the accuracy of their company's parent organization and legal entity name in the Health Plan Management System (HPMS). The memo requested Plans to report any necessary corrections by March 16th. Continue Reading


March 2015
Progress Notes:
CMS Compliance for Data Management


As we mentioned in previous missives, compliance with CMS regulations for data management is a big theme this year.  CMS provided two HPMS memos recently that are relevant to PACE organizations that wish to demonstrate compliance in an important way.  The first memo on Feb 18 refers to the requirement for PACE Organizations to return overpayments to CMS in a timely fashion (defined by the Affordable Care Act as within 60 days after the overpayment is identified).


Most overpayments are due to submitting erroneous data to CMS and the following four general categories of data submissions that have the potential to result in overpayments:

  • Risk Adjustment (Risk Adjustment Processing System (RAPS) data and encounter data)
  • Prescription Drug Event (PDE) and Direct and Indirect Remuneration (DIR)
  • Low Income Premium Subsidy (LIPS) for Employer Group Waiver Plans (EGWPs)1
  • Other

Additional information about these categories is provided in the memo.  For practical purposes in PACE Organizations (PO), the most common errors are diagnosis codes that submitted to RAPS, but are not supported by the medical record. Continue Reading.

The ABD's of Medicare:
Renal Transplant

PACE programs don't often face the possibility of a participant receiving a renal transplant. However, most Executive Directors and Medical Directors worry that, should that situation arise, that the cost would be prohibitive and that their program could never absorb the financial burden. Fortunately, that is not the case.
Your dialysis participants don't use the Version 21 HCC model that is used to calculate risk scores for your other participants. Instead they use CMS HCC - ESRD model. Imbedded into that model is funding for a renal transplantation. The model looks at the cost of renal transplantation incurred over three months. Through the development of new risk scores (which won't be dealt with here), CMS pays over 50% of the cost for the transplantation in the first month and the remainder divided equally over the next two months. Continue Reading


Documentation Dispatch: 
Depression Vs. Major Depression

When documenting depression, it is important to document completely and accurately in order for the most appropriate and specific code to be assigned.   The correct diagnosis and ICD-9 code may be the difference between a diagnosis that maps to an HCC and one that does not.  For example, ICD-9 code 311 (depressive disorder, NEC) does not map to an HCC, but 296.XX (major depression) maps to HCC 58. 


There are not DSM IV criteria for "depression" and "major" depression; only criteria for Major depression.   If the criteria listed in the DSM IV is met, documentation should reflect major depression.  Major depressive disorders are classified in ICD-9-CM as episodic mood disorders with category 296.  The fourth digit, 296.2x and 296.3x, is coded to define a single or recurrent episode respectively.  When applicable, designate major depression as recurrent and code 296.30, if the condition has known episodes with complete recovery between.  If a provider documents only major depression, the correct code, per ICD-9 guidelines, is 296.20.


The fifth digit is coded to define the severity of the current depressive episode:  0 - unspecified; 1 - mild; 2 - moderate; 3 - severe, without mention of psychotic behavior; 4 - severe, specified as with psychotic behavior. Continue Reading



If want to learn more about how we help PACE programs succeed, and you are planning to attend the North Carolina PACE Association conference, please stop by and visit Dr Mike Brett and Matt Zimmerman at the Capstone Booth.



Best Regards,   

Neta Kessler MS
Operations Manager
Capstone Performance Systems

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