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 coding@scanhealthplan.com.