Updates!

With the ICD-10 implementation date just around the corner, we at SCAN, and you as our Provider partners are working very hard.  There's so much information to filter through, it sometimes seems impossible to keep up with.

CMS has posted their DRAFT CPT/HCPCS filtering list.  What is on the list is not hugely problematic, but what's missing (Modifiers) is.  As you know, modifiers alter the meaning of the CPT/HCPC codes, and inclusion of some of those modifiers may be important.  Health Plans have until August 21st to comment.  You can rest assured that we're studying the list, and will make comments to CMS in a timely manner.

CMS also posted another important file: The updated CMS-HCC and Rx-HCC files.  As you know, CMS posted a draft file a little over a month ago--they've now taken it down and replaced it.  They are not calling this the final ICD-10 mapping, so we'll be sure to monitor the CMS website and post updates here.

We've posted a number of new Q and As on the Ask-a-coder page.   In addition, we've completely new Helpful Links page.  All of the links are now categorized, making it easier for you to find exactly what you're looking for.

Just as an FYI--when we have special or time sensitive posts to HCCUniversity.com, we usually send out an email blast.  These are sent infrequently, and usually no more often  than once a month.  If you'd like to be added to our growing list of HCCUniversity readers, please send your name and email address to coding@scanhealtplan.com, and we'll be sure to add you.

That's it for today.  As we get closer to ICD-10, we 're sure to hear things from CMS that are of importance to you. We'll pass them along here, on HCCUniversity.com and through our email blasts.


Stacey Hernandez, CCS-P          

Advance Notice of 2016 Medicare Advantage and Part D Rates Released

On Friday, February 20, CMS released the proposed rules for Medicare Advantage Payment for 2016.

Comments to the proposed rule are due to CMS on March 6, 2015.  You can download the proposed rule on the CMS website.

The final rule will be released on April 6, 2015 in accordance with the law, and you'll be able to download it on the Announcements and Documents Page.

For an easy to read summary of the notice, you can download the CMS Press Release.

CMS plans to completely phase in the new CMS-HCC model, with no blend.

In addition, CMS is proposing that they will calculate 2016 MA and Part D risk scores by blending two separate risk scores.  One risk score would be calculated using 2015 diagnoses from the Risk Adjustment Processing System (RAPS) and Fee-For-Service (FFS) data, and another separate risk score would be calculated using 2015 diagnoses from the Encounter Data System (EDS) and FFS.  CMS would then blend these two risk scores, weighting the risk score from RAPS and FFS by 90% and weighting the risk score from EDS and FFS by 10%.  This will make the subission of all encounter data more important than ever before.

CMS has decided not to disallow services performed in the home setting, but health plans still must report services performed in the home.

We suggest you review the CMS documents, and download the final rule, which will likely be released late in the afternoon of April 6, 2015.

New Presentation on HCC University

There is a new presentation and quiz on HCCUniversity.com, 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: http://www.hccuniversity.com/hcc-university/training-presentations/2014-cms-hcc-model/

 

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

 

Risk Score Calculator Updated with 2014 Model

The Risk Score Calculator on HCCUniversity.com 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.

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.

What's New On HCC University

We've posted an updated list of Payment Year 2013 (2012 DOS) diagnoses in the CMS HCC model on the Tools Page.  You can download the Excel file here.

In addition, we've updated our Risk Adjustment 101 presentation.  You may want to use it in training new staff.  It's on our Training and Presentations page.

CMS Full Encounter Updates

CMS is currently holding technical assistance meetings for health plans across the country.  SCAN representatives attended the July session in San Diego the week of July 11.

A lot of issues remain up in the air, but we do know a few things.

• CMS is holding fast on the subject of the 13 month timely filing.  Plans are given an additional month over the 12 month FFS timely filing to account for the submission from provider to plan to CMS.   There is discussion of filing benchmarks and we hope to know more about this after the final session ending the first week of August.
• Plans cannot make material corrections to claims/encounters, this must be done by the provider of service.  For example, diagnosis codes, procedure codes and other fields involved in pricing the claim (e.g., addresses, modifiers) must be corrected by the provider.
• Full 9 digit ZIP codes will be required on claims/encounters.
• CMS has clarified that the only dental claims that will be required are those that are covered by fee-for-service Medicare.  This includes jaw reconstruction after an accident, and examinations (no treatment) prior to kidney transplants and some heart valve implants.  If the services are performed by a hospital based dentist (rare) then the submission must be on the 837 I, and if performed by a dentist in private practice, on the 837P.  No 837D (dental) claims will be accepted by CMS.
• \CMS has no projected date for a draft of the CMS-HCC model with ICD-10 codes.  There was also no update about a move to the new 87 disease CMS-HCC model.

As we learn more from CMS about full encounter data requirements, we'll post it here.

Please let us know if there are any specific issues you'd like to see in this space.  You can leave us a comment, or email us at coding@scanhealthplan.com.

Recently Posted Tools and Documents on HCC University

We want to ensure that HCC University and the HCC University blog are your favorite risk adjustment related websites.  So, over the past few weeks, we’ve posted a large number of tools and documents on HCCUniversity.com.  Since none of us has time to check every day, we thought we’d give you an overview of what’s gone up on the site recently.

Full Encounter Data Information -  ICD 10/Full Encounter Data Page

Updates from the CMS Work Group Conference Calls have been posted:

Capitated and Staff Model Plans Summary Notes

Encounter Data Newsletter - Quarter 2

Encounter Data Work Group Summary Notes for Editing and Reporting: Key Findings and Recommendations #2

Third Party Submitters Work Group

Risk Adjustment Tools

2011 HCC List-Diagnosis Code Grouping - this file shows diagnosis codes grouped by HCC category.  Categories or codes with problematic guidelines have documentation and coding notes. - Excel file here.

Risk Adjustment Data Validation Tools

This checklist was used in the last National RADV to assist health plans in selecting the "One Best Medical Record" for submission.  Download here.

CMS Pilot RADV Findings—for services rendered July 1, 2001 through June 30, 2002, Published July 27, 2004.  Study findings here.

Annual Wellness Visit Tools

Annual Wellness Visit Presentation --Power Point Presentation.

Annual Wellness Visit form, instructions, and USPSTF Preventive services schedule - Zip File Here.

If you have questions, comments, or suggestions for new tools, leave us a comment here, or email us at coding@scanhealthplan.com.

2012 CMS-HCC Model Diagnoses Posted

CMS has posted the diagnoses for the CMS-HCC, ESRD/PACE-HCC, and Rx-HCC models.  You can download the file from the CMS website here: 2012 Model Diagnoses (with FY2011 ICD-9-CM) (ZIP, 167 KB) .

Within the next couple of days you'll be able to download the file form our Tools Page on HCC University here.  Scroll down to "Downloadable Tools" and it will be the second file.

Watch this space for more information.

2012 Announcement Posted on the CMS Website

You can download the announcement here: 2012 Announcement.

As CMS indicated in the Advance Notice, there will not be a change to the CMS-HCC model for 2012, so that plans and providers can focus on other upcoming changes.

CMS also added several specialties to the acceptable physician specialties for risk adjustment, and deleted one tyep.

The additions are: Interventional Pain Management (IPM) (code 09), Speech Language Pathologist (code 15), Hospice and Palliative Care (code 17), and Geriatric Psychiatry (code 27). Note that Multispecialty Clinic or Group Practice (code 70) is not an Acceptable Physician Specialty Type.

More information will be posted as it becomes available.

2012 Combined Advance Notice and Call Letter Posted to the CMS Website

The 2012 Advance Notice of Methodological Changes for Calendar Year (CY) 2012 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2012 Call Letter has been posted to the CMS website at: 2012 Advance Notice and Call Letter.  


Although we have not had time to analyze the notice in detail, CMS is proposing not to implement the new model that was proposed for Part C for 2012 in order to minimize changes during 2012.

Based on the proposal released on Friday, there will be no changes to the CMS-HCC Model for 2012.  CMS will not implement previously proposed changes (e.g. addition of dementia and morbid obesity) until 2013 at the earliest, unless they change what is in the Advance Notice.  We will know with certainty on April 4, 2011 when the Announcement is published, but at this time, it is extremely unlikely that the model will change in 2012.

We will have more information for you at a later date.

Changes to the CMS-HCC Model for 2011

As noted in our last post, the updated CMS-HCC Model codes were posted to our website on 9-29-2010.  You can view the file on our Tools Page.  But, what are the changes to the model for 2011?

In short, CMS has:

• Deleted two codes from the model --279.4 and 453.8.  Both of these codes are truncated codes, i.e., not at the highest level of specificity
• Deleted three codes from HCC 80--404.03, 404.93 and 404.13.  Note that these codes all still map to HCC 131
• Added 8 new codes to the model. All of these codes are new ICD-9 codes.  While the codes are effective 10-1-2010, they do not count in the CMS-HCC model until 1-1-2011.

See below for details.

ICD-9-CM Code	ICD9_Description	CMS-HCC Model Category	CMS HCC Model 2011	Action Taken	Comments
40413	Ben Hyp Ht/Kid W Hf/Kid	80	No	Deleted from this HCC	Although this diagnosis remains in the model under HCC 131, it no longer maps to HCC 80.
2794	Autoimmune Disease Nec	45	No	Deleted from the model	This diagnosis code was removed from the model. It is not at the highest level of specificity, and more specific codes in this section remain in the model.
4538	Venous Thrombosis Nec	105	No	Deleted from the model	This diagnosis code was removed from the model. It is not at the highest level of specificity, and more specific codes in this section remain in the model.
40493	Hyp Hrt/Kid Nos W Hf/Kid	80	No	Deleted from this HCC	Although this diagnosis remains in the model under HCC 131, it no longer maps to HCC 80.
40403	Mal Hyp Hrt/Kid W Hf/Kid	80	No	Deleted from this HCC	Although this diagnosis remains in the model under HCC 131, it no longer maps to HCC 80.
44770	Aortic ectasia, site NOS	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
56032	Fecal impaction	31	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
23773	Schwannomatosis	10	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
23779	Neurofibromatosis NEC	10	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
78033	Post traumatic seizures	74	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
44773	Thoracoabd aortc ectasia	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
44772	Abdominal aortic ectasia	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.
44771	Thoracic aortic ectasia	105	Yes	Added	This is a new diagnosis code for 2011. The code is effective 10-1-2010, but not included in the model until 1-1-2011.

If you have questions or comments about this posting, or have ideas for future postings, please let us know by leaving a comment!

New ICD-9 Codes Added to CMS-HCC Model

CMS published the new codes for the CMS-HCC model today on their website.  The new codes are effective 1-1-2011, and include a number of the new 2011 ICD-9 codes.  *While the ICD-9 codes are effective 10-1-2010, they are not included in the model until 1-1-2011.*

You can find the file on HCC University on our Tools Page.

The following codes have been added to the CMS-HCC or the RxHCC model:

Please note that there may be new codes added in 2011 due to changes in the CMS-HCC model.  The first (proposed) announcement of this will occur in February, with the final announcement of changes in April.  These changes will be posted here as soon as they become available.