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!

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 HCCUniversity.com.

 

 

 

 

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 http://cms.meridianksi.com/kc/ilc/course_info_enroll_lnkfrm_f1.asp?lgnfrm=wbt&table=crs&function=course_info_enroll&strBuildingID=5&strFunctionID=37&strFunctionPath=37&strFrom=Search&topic=All&keywords=

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.