HCC Blog by Caridad

 From the email Office of Inspector General (OIG) newsletter covering 2024 Nationwide Health Care Fraud Enforcement Action: The OIG reviewed Independent Health Association, Inc. (IHA) (Contract H3362). OIG concluded that most of the selected diagnosis codes submitted by IHA were submitted to the Centers for Medicare & Medicaid Services (CMS) for use in CMS’s risk adjustment program did not comply with Federal requirements. This resulted in $646,217 in overpayments The audit covered the enrollee-years for 2016 and 2017. OIG performed audit work from September 2019 through June 2024.  The OIG concludes that as they found errors in their sample, IHA’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. IHA disagreed with some of the findings, specifically the findings for 17 of the 232 enrollee-years. They did not agree with the audit methodology, use of extrapolation and...

 Are seizures and epilepsy the same thing? ¿Es el mismo perro pero con distinto collar? Seizure and epilepsy are related but distinct medical terms: 1. A seizure refers to a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in behavior, movements, sensations, or consciousness. Seizures can vary widely in their presentation, from mild staring spells to convulsions or loss of consciousness. 2. Epilepsy is a neurological disorder characterized by recurrent seizures. It's diagnosed when someone has had two or more unprovoked seizures. Epilepsy can have various causes, including genetics, brain injury, infections, or developmental disorders. It's a chronic condition that requires ongoing management and treatment.   In summary, while a seizure is a single event, epilepsy is a neurological disorder characterized by recurrent seizures. Not all seizures indicate epilepsy, but epilepsy is defined by the occurrence of seizures and this is important in I...

  From the May 1 2024 Memo from CMS they outlines the "Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2024, 2025, and 2026". https://www.cms.gov/files/document/py202420252026submissiondeadlinememog.pdf Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.

Have you ever wondered how providers in the same specialty and area compare?  On this site you can see how a provider compares to their peers.  Information on services and procedures provided to Original Medicare (fee-for-service) Part B (Medical Insurance) beneficiaries by physicians and other healthcare professionals; aggregated by provider. Does not contain Medicare Advantage plans data.  click on View Data https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-provider The Medicare Physician & Other Practitioners by Provider dataset provides information on use, payments, submitted charges and beneficiary demographic and health characteristics organized by National Provider Identifier (NPI). Enter the provider's name to perform a search.

Below are links to the list of Medicare Risk Adjustment Eligible CPT/HCPCS Codes. There are files for various years. Find the CPT code on the list to verify if those visit types are risk adjustment eligible.  Medicare Risk Adjustment Eligible CPT/HCPCS Codes outpatient inpatient skilled nursing facilities Medicare Risk Adjustment Eligible CPT/HCPCS Codes https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats/risk-adjustors-items/cpt-hcpcs Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.

  These are the HCC categories in CMS-HCC V28.  CMS-HCC v28 HCC 35 Pancreas Transplant Status   HCC 36 Diabetes With Severe Acute Complications (rarely occur in outpatient setting)   HCC 37 Diabetes With Chronic Complications (higher level of severity of illness)   HCC 38 Diabetes With Glycemic, Unspecified, or No Complications   They all provide the same impact to the risk adjustment factor (RAF) score. The previous extra bump in risk adjustment factor for diabetic complications has been removed in this version.   Document linkage of diabetes to any and all manifestations.    2024 payments are based on 2023 dates of service. Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It i...