Monday, December 16, 2013

ICD-10 Basics MLN Connects Video

Hi all.   Did you know that CMS has a You tube channel?  I didn't either.  But they do, and have a number of ICD-10 training videos.  I'll be posting them over the next few weeks, to help you with your ICD-10 training needs. 

Thursday, December 12, 2013

Health Risk Adjustment Flags

Health Risk Assessments (HRAs) in the Risk Adjustment Processing System Transactions
In the 2013  In the November 2013 Software Release, CMS acted on their stated intention to gather information on enrollee health assessments or "health risk assessments" or HRAs.  
The Software release provided little information, and most health plans held off publishing information until we had additional information and clarification.  On December 5, 2013, we received some clarification during a Risk Adjustment User Group Call with CMS, where no questions were taken.
According to the initial explanation:
The Risk Assessment field must contain one of the following values:
A. Diagnosis code comes from a clinical setting.
B. Diagnosis code comes from a non-clinical setting and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit were met.
C. Diagnosis code comes from a non-clinical setting and originates in a visit where all requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or Subsequent Annual Wellness Visit were not met.
Health Plans requested clarification from CMS on the following:
1)    What is a "non-clinical setting"?
2)    Are Annual Wellness Visits the only services covered by Flags/Values 'B' and 'C'?
3)     Does the providers' credential have anything to do with use of the flags?
4)     Does use of any of these flags indicate that the service will not be risk adjusted?
To the best of our understanding at this time, the answers to these questions are as follows:
1)     The patients home is the only non-clinical setting they are referring to
2)     based on 42 CFR 410.15 (a), Initial Preventive Physical Exams, the "welcome to Medicare     physical is also included.
3)      The providers' credential has nothing to do with assignment of the flags.
4)       At the present time, the use of any flag will not affect risk adjustment.  A final policy will be published in the 2015 Advance Notice in February, 2014.
So, to answer what falls under 'A', 'B' and 'C'?  Very simply, this:
A--Any risk adjustable service not done in a patients' home.
B--Any risk adjustable service which is procedure code G0402, G0438 or G0439 and is not performed in the patients' home.
C--Any risk adjustable service which is not procedure code G0402, G0438 or G0439 and is performed in the patient's home.
In order for health plans to accurately assign the correct indicator, it is critical that you submit the accurate place of service and procedure code on all encounters, including abbreviated format encounters.
We hope this helps answer some questions about the Health Risk Assessment Flags.

Remember, if you have questions about ICD-9 Coding, or have suggestions for future blog postings, contact us at

Wednesday, September 18, 2013

MedLearn (CMS) Web Based Training Programs -- Free CEUs, CMEs (2 Courses) From Multiple Organizations

CMS offers a number of Web Based Training (WBT) programs which offer CEUs which should be of interest to Coders and others.  Of special interest to everyone involved in risk adjustment is a CBT on Part C and Part D Risk Adjustment.   Two of the WBTs even offer CMEs approved by the AMA:

  • Safeguarding Your Medical Identity
  • Avoiding Medicare Fraud and Abuse: A Roadmap for Physicians

The following organizations offer continuting education credits:

·         American Association of Medical Audit Specialists
·         American Medical Billing Association
·         California Certifying Board for Medical Assistants
·         Healthcare Billing & Management Association
·         Medical Association of Billers
·         National Academy of Ambulance Coding
·       American Association of Medical Assistants
·       AAPC

And don't forget, SCAN Health Plan also offers free Continuing Medical Education on!

Wednesday, September 4, 2013

New Presentation on HCC University

There is a new presentation and quiz on, with a corresponding quiz that you may be interested in.  The presentation covers changes to the CMS-HCC model, including things like the addition of Morbid obesity, and fibrotic lung diseases.  It also covers the deletion of previously included codes, like CKD stages I-III and polyneuropathy.  There are documentation tips for some of the new procedure codes, as well as some lessons learned from the last CMS Risk Adjustment Data Validation Study.  Finally,  there is a quiz, to help you test your knowledge of the new model and the common documentation errors that physicians encounter.  We urge you to share this  presentation and quiz with everyone involved in risk adjustment in your organization, especially physicians and physician extenders who may benefit from the documentation tips.  You can review the presentation at:


If you are interested in having a webinar training session to cover the presentation, please feel free to contact us at


Friday, August 23, 2013

Coding BMI

We've gotten several questions lately about the requirements for coding BMI, asking why BMI can't be coded if documented, but there is no documentation by the physician regarding obesity/morbid obesity, etc.

The Official ICD-9 instructions have been revised to indicate that the BMI may be documented by someone who cannot make a diagnosis, such as a dietitian.  However, they go on to state that the BMI is always a secondary diagnosis, and the physician must document the related diagnosis, such as overweight, obesity, etc.

This is further supported by Coding Clinic, Q2, 2010 which confirms that the BMI may be recorded by non-physician clinicians, like nurses or dieticians, but it cannot be reported (coded) unless there is also documentation by the physician of the related condition, such as overweight or obesity.

Therefore, it is not appropriate to assign the code for BMI unless the related diagnosis is also documented and reported.

We hope this helps understand the Official ICD-9 Guidelines for reporting BMI.

Thursday, August 15, 2013

New ICD-10 Resources Available!

CMS has published the new version of the ICD-10 CM and GEMs (the General Equivalence Mappings).  In addition, they have posted some new ICD-10 tools, for providers to use:

These three new CMS publications should help you in developing new superbills and coding sheets for your office.

Wednesday, August 7, 2013

More Full Encounter Data Tips

Issues in Encounter Submission

Remember that Full Encounter Data (FED) submission closely mirrors Fee-for-Service (FFS) claims submission.  Therefore, you should run reports against encounters submitted under FED that were rejected by CMS:

·        While the Companion Guides help with creating and submitting an EDI transaction, there are a number of billing guides produced by Medicare Administrative Contractors that give advice on claim submission.

·        In addition, the website also has instructions for claim submissions as well.  Check the Claims Processing Manual chapter(s) that relates to your type of service.

·        The focus of the guidelines on the CMS website is more on claims submission and payer processing of claims/encounters for adjudication.  Following the instructions on both of these websites will help you produce encounters which can be processed successfully.

The following websites have billing information to help you file correctly:


DMEPOS and PEN Submission                                                  


Possible Systemic Issues to Identify and Correct

·        Incorrect modifier for HCPCS/CPT code (e.g. surgical modifier on an E/M code).

·        Incorrect dates of service - Many DMEPOS services require a span of dates of service—for example, rentals and a month’s worth of supplies.  The dates of service should be the 30 day span that represents the rental or supply period.

o   Note that the number of services should reflect the number of days for a rental, or the number of units for supplies.  Do not default to “1” in these situations.

·        Use the correct place of service.  The place of service for DME must be the patient’s home  (POS 12).  Rarely, a Skilled Nursing Facility or Nursing Facility is appropriate (POS 31 or 32)

·        Some services have specific diagnosis requirements—“CPAP” or “BiPAP” machines require specific diagnoses.   All services except the few screening services allowed require a specific diagnosis related to the service.

·        Incorrect number of services (e.g., 1 service for 30 day span). Number of services should be evenly divisible by the date span.

·        Missing critical information—e.g. ordering provider, rendering provider on a medical group or DME claim/encounter.

·        Incompatible place of service (i.e.  Outpatient service like 99214 billed with Place of service 21, 31 or 32).

·        Incorrect or missing origin/destination for ambulance claims.


We hope that this information helps you in your goal of submitting clean FED claims/encounters.




Wednesday, July 31, 2013

Gearing Up for ICD-10

There are thousands of articles out there on getting ready for ICD-10 implementation.  Most of them are very broad in their scope.  One item that sometimes gets short shrift is planning for new superbills in the physician office setting.

Maybe because it seems overwhelming--or maybe because the writers often come from a hospital setting.  In the hospital setting, coding is much different.  The query process means that you can start off with documentation that is of low specificity, and end up with more specificity to improve code selection.  In all but the largest of physician clinic settings, there is no query process.  The documentation is what it is.

So, what advice can we give to the practicing physician, who may be overwhelmed with the large number of codes available?  I think the most important thing for physicians to do is be realistic about their documentation (while taking the opportunity to improve it!), and analyze what they really use in ICD-9 as a starting point.  Your superbill may contain 100 ICD-9 codes, that translate to 2,500 possible ICD-10 codes.  But how many of those ICD-9 codes do you really use and document in your day to day practice? That old clinical saw about horses vs. zebras will serve you in good stead here too.

Use your practice management software to analyze the top 100 codes you use today--not what is on your superbill.  Look at the frequency of use over the course of a year.  If 25 of those codes make up 80% of your ICD-9 volume, turn to the General Equivalence Mappings (GEMs) to help you find crosswalks for those codes.  Allow plenty of space for write in- diagnoses in the beginning--and track those codes.  Take the top 25-50 of your write- in codes, and add them to your superbill.   By the time you have 75 codes on your superbills, MOST specialties will have a superbill that helps you code 80% or more of your daily visits.

Some specialties (orthopedic surgery, for example) will be forced to create much larger superbills, unless they limit their practice to a specific body part.  But the basic premise is the same.  However, because of the specificity of ICD-10, and the few areas of the code book that do not contain a "Not Otherwise Specified" code, you'll be forced to change your documentation style, or be unable to find codes for some conditions.  Remember that anatomy and laterality are key in ICD-10, along with dominance (mostly for neurological conditions).  Your documentation should indicate R vs L, along with whether the patient is R or L hand dominant.  You might have been able to find a code for "R arm fracture" in the past, but now you'll need to document the bone(s) involved, including the area of the bone involved.  This does mean some increase in documentation, but these increases have the potential to improve documentation greatly.  Continuity of care can be improved with these changes, and exchange of important clinical information between specialties.

Whatever approach you plan to take to create superbills in ICD-10, the time to start is now.   Today, there are 426 days until ICD-10 submission is required.  Waiting until then to see what is required is too late.  Starting now will allow you the necessary time to make any changes needed in your documentation, and begin to understand the differences in ICD-10 language and rules.  Take the time now to read the official guidelines (even if you've never read the ICD-9 guidelines!) so you know what the requirements are to choose a code.

Remember to check the Presentation and ICD-10 pages on HCC University for information on ICD-10 coding.  And let us know what types of information you need on ICD-10.

Monday, July 29, 2013

Risk Score Calculator Updated with 2014 Model

The Risk Score Calculator on has been updated with the 2014 CMS-HCC Risk Score Calculator.

The calculator will allow you to calculate risk scores for services on or after 4-1-2013.  The updated calculator shows the components of the 2013 (25%) model and the 2014 (75%) model, and the final blended score.

We hope you find this new tool useful.

Wednesday, July 24, 2013

CMS Rejects of Full Encounter Data Encounters

Even after more than a year, we continue to see a number of CMS rejects of submitted encounters.  These rejects occur in all types of encounters, and for a number of reasons.  One of the most common rejects we see is for the referring physician's NPI.  This happens in a number of types of encounters, but most commonly in DMEPOS encounters.  Let's look at encounters missing a referring physician NPI,  and the various errors we see in them:

1)      Incorrect DOS—most DMEPOS are rentals, or represent a monthly supply.  Almost all of the encounters I saw were for a single date of service, and should be a 30 day  span—e.g. from January 1-30. 

2)      Incorrect # of services—many of the DMEPOS encounters have a # of services “1”—when it should be “30”.

3)      Incorrect place of service—in almost all cases, DMEPOS requires a POS of 12 (sometimes 31 or 32 if that’s the patient’s home).  Many of these encounters have a POS 11 or 99.

4)      Missing modifiers (things like Anesthesia always requires a modifier, some surgeries require a modifier to indicate if they are RT, LT or bilateral –50. Most DMEPOS have modifier requirements as well)

5)      Unlisted E/M (99499).  While this code would be expected for a chart review submission, many of these are WITH another E/M on the same date, which makes no sense--generally only one E/M service is allowed on a given day.

Remember that your encounter data to MA plans should be submitted as you were submitting to your MAC, FI or DMERC--because in effect you are.  We must submit all of your encounters to CMS for processing on the same claims processing systems that the MAC, FI and DMERC use.  So, if the claim or encounter won't pass your Medicare contractor's processing system edits, then it won't pass the encounter data processing system edits either. 

The closer your encounter data submissions are to FFS Medicare, the more likely they are to be processed by CMS.

Monday, July 22, 2013

New Medicare Presentations Posted on CMS Website

CMS has posted a number of new presentations on their website, to help providers with CMS Fee-for-Service (FFS) quality programs.  While these presentations deal with FFS quality programs, the documentation for several of these programs are similar to the documentation required for the HEDIS and Five Star programs in Medicare Advantage.  You can take these programs by following the information below:

The PowerPoint presentations and recordings from past webinars can now be accessed on the Resources page of the eHealth website.

The following webinar resources are available:

We hope this information proves helpful!

Wednesday, May 29, 2013

Life Threatening Conditions Fact Sheets

One of the questions we receive most frequently is "Can we submit ______________________ diagnosis in an office setting?"

The answer is:  If the condition is life threatening, and there is no indication that the physician either called 911 or instructed the patient to go to the hospital (even if they refuse), then it is not appropriate to submit a life threatening diagnosis.

We recognize that sometimes patients either go to the doctor's office with a life threatening condition, or one develops while they are there.  However, we expect to see some indication that the physician treated the condition as an emergency.

Most often, physicians document these conditions because they don't realize that they should clearly indicate that it is a "history of" the condition, not a current illness.  In order to help physicians understand appropriate documentation and coding, we've developed  a series of "Life Threatening Conditions Fact Sheets", which you can download from HCC University.  The fact sheets below are available.  If you think others are needed, please send us an email to, and we'll see if we can develop one.

We hope you'll use these fact sheets to help educate the physicians in your practice.

If you have questions about the content of these fact sheets, please let us know.

Tuesday, April 23, 2013

CMS Contractor hosting ICD-10 End-to-End Testing Webinars

National Government Services (NGS), under contract to CMS, is hosting a series of webinars on  ICD-10  end-to-end testing.   The schedule of webinars (all Eastern time) is listed below.  You can register for the webinars by emailing

May 7, 2013
2-3 p.m.
Small Provider
May 8, 2013
2-3 p.m.
Large Provider
May 9, 2013
2-3 p.m.

In addition, NGS has created an End-to-End Testing checklist, which will be discussed during the webinar. 

Thursday, April 11, 2013

ICD-9 Codes in the Revised 2014 CMS-HCC Model Available on HCC University Now

CMS has posted the  2014 payment year CMS-HCC SAS Software on their website.

Part of this software is a file which contains the ICD-9 codes and HCC groupings for 2014 payment which we have posted on HCC University.

The original file contained some ICD-9 codes which were not at the highest level of specificity.  These codes were removed from the file before posting on HCC University, since CMS will reject them from RAPS submissions.

Wednesday, April 3, 2013

Risk Adjustment Changes for 2014

CMS has announced a new CMS-HCC Model for payment year 2014 in their combined  Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter, published April 1, 2013.  You can download a copy of the ICD-9 codes that CMS released at the time of the Advance Notice [here].  CMS has not informed us of any changes in this listing, but we will advise you immediately if they do.

Important provisions of the announcement, related to Risk Adjustment:

                          Clinically Revised CMS-HCC Model.  CMS will implement the new risk adjustment model, but will phase-in changes over a two year period.  In 2014, CMS will blend 75 percent of the 2014 model risk score with 25 percent of the 2013 model risk score.  The new model will be fully phased-in by January 1, 2015.


                          Medicare Enrollee Health Risk Assessment.  As we noted when the Advance Notice was published, CMS is considering excluding from risk adjusted payment any diagnosis data collected from MA enrollee Health Risk Assessments which are not confirmed by a subsequent clinical encounter.  CMS planned to collect flags in 2013 of these risk assessments.
Based on comments received, CMS is delaying the collection of flags until calendar year 2014.  Further determination about exclusion of these data will be published in the 2015 Advance Notice


                          Coding Intensity Adjustment.  The Coding Intensity Adjustment for 2014 is 4.91 percent.


                          Normalization Factor.  Because 2014 payment will be based on a blend of the old and new CMS-HCC Models, there will be two normalization factors:

• 2013 CMS-HCC model: 1.041.

• 2014 CMS-HCC model: 1.026.


You can review all of the changes for 2014 in the Announcement, posted [here].   Look for new training programs to help SCAN providers understand the changes to the model on HCC University soon!

Wednesday, March 13, 2013

2014 Advance Notice Released

On Friday, 2/15/2013, CMS issued the combined 45 day Advance Notice and Call letter,  which describes proposed changes related to the CY 2014 Medicare Advantage (MA) and Part D payment methodos.  Some important Medicare Advantage proposals in the notice include:


·         Growth Rates The transition to the payment methodology enacted in the ACA will cause the pre-ACA payment methodology to be phased-out over several years through MA county rates.
·         Coding Intensity Adjustment  In 2010, CMS began applying a coding intensity adjustment to the Part C risk scores to account for the difference in coding patterns between MA and  FFS Medicare.  In the Advance Notice,  CMS is proposing an MA coding pattern difference adjustment of 4.91% for payment year 2014, which is the minimum coding intensity adjustment required under the ACA as amended by the American Taxpayer Relief Act of 2012.  The coding intensity adjustment applied in 2013 was 3.41%

·         Clinical Update and Recalibration of the CMS HCC Risk Adjustment Model – CMS has proposesd an updated CMS HCC Risk Adjustment model for 2014 tas a result of a clinical review of diagnoses included in each HCC. 

The changes are intended to address higher rates of coding of some HCCs by MAOs compareed to FFS providers.  If implemented, the number of HCCs will increase from 70 to 79  and CMS plans to recalibrate the model. 

This will cause a reduction in the value of a number of HCCs.  CMS is proposing a phased-in implementation of the new model over a multi-year period.  For 2014, CMS would implement coefficients of the revised model but would transition over a multi-year period to the revised model denominator.

·         Fee-for-Service Normalization Factor –   The estimated FFS Normalization Factor for 2014 will be 1.026.  It was 1.028 in 2013.

·        Medicare Advantage Health Risk Assessments – CMS notes that Health Risk Assessments (HRAs) are being done to assess the health of MA members, but feels that they are also used to  identify diagnoses for submission to CMS for risk adjustment purposes.  CMS is concerned that in some cases, diagnoses are reported without follow-up care or treatment being provided to MA members.  CMS intends to implement a data collection that will require that MA organizations flag those diagnoses collected as part of an HRA, beginning with 2013 dates of service.   CMS will also be considering ways to ensure the accuracy and completeness of this risk assessment information.  Beginning in 2015, CMS may exclude a  diagnosis from risk adjustment payment  any HRA diagnoses that are not confirmed by a subsequent clinical encounter by an approved provider type (e.g., the member's PCP) for risk adjustment. 

Final provisions will be released on April 1, 2013, and we will post them as soon as possible.  You can review the Advance Notice and Proposed Model Diagnoses on





Thursday, January 31, 2013

New Medicare Web Based Training (WBT) Modules

CMS has re-vamped their World of Medicare training course. Formerly, it was a single 1 hour WBT.  Now it is 4 parts, and is followed by either the Your Office in the World of Medicare or Your Institution in the World of Medicare.  These WBTs provide a great introduction to fee-for-service Medicare.  If you've ever been confused by the many rules of Medicare, you may want to check out these WBTs. 


The World of Medicare targets both physicians and providers as well as administrative staff.  Your Office and Your Institution are aimed at physicians, providers and their staff who are enrolling in the Medicare program, to provide assistance in completing the 855 (enrollment) forms.

These and all of the Medicare WBTs can be accessed at

Monday, January 14, 2013

What's New on HCC University?

We've continued to add a number of documents to HCC University to make your documentation and coding go more smoothly!

We've updated our Annual Wellness Visit (AWV) with Health Risk Assessment (HRA) package to incorporate information on 5Star coding.  Since physicians are already capturing the data, we want to help make it easy to remember to submit it on the Superbill.  You can also review a presentation on completing the AWV with HRA.

We'll be posting more documents on HCC University in the near future.