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.

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.

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:

• Quality Measurement 101: What Providers Need to Know about CMS Quality Programs (July 16, 2013)
• PowerPoint Presentation
• Webinar Recording

• Intro to the EHR Incentive Programs for EPs: Basic Eligibility and Payment Information, Review of Key Deadlines (July 2, 2013)
• PowerPoint Presentation
• Webinar Recording

• EHR Incentive Programs: Stage 2 Overview, Audits, and Payment Adjustments (June 20, 2013)
• PowerPoint Presentation
• Webinar Recording

• Advancing Interoperability through Meaningful Use: A Refresher Course (June 6, 2013)
• PowerPoint Presentation
• Webinar Recording

We hope this information proves helpful!

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 coding@scanhealthplan.com, and we'll see if we can develop one.

• Sepsis Fact Sheet
• Acute MI Fact Sheet
• Unstable Angina/Acute Coronary Syndrome Fact Sheet
• Acute Respiratory Failure Fact Sheet
• Acute CVA Fact Sheet

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.

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 ngs.compliancetesting@wellpoint.com.

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.	Vendor

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

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.

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!