Updates for Encounter Data and Risk Adjustment in 2015

From: Scan Health Plan http://hccublog.scanhealthplan.com/

Important Encounter Data Reminders and Updates

Remember, effective July 2014, Medicare has implemented the 13 month processing window for timely filing of encounter data.  Encounters older than 13 months will receive an informational edit from CMS—but this will change to a reject, which could happen at any time. Remember, that your encounter must be processed by SCAN first, so it’s important that encounters be received in advance of that 13 month time limit.  We expect to receive notice from CMS prior to them beginning to reject encounters.

Adjustments are not subject to the 13 month window,   but SCAN must submit them to CMS within 30 days of their adjudication.

 
Encounter Data Processing System

Both the Risk Adjustment Processing System (RAPS) and the Encounter Data Processing System (EDPS) will be used in 2015.  CMS will make an announcement prior to discontinuing RAPS and moving to only EDPS for risk adjustment calculations.

CMS Announcement for new HCPCS modifier codes to replace modifier -59. Effective January 1, 2015. Read the full release HERE.   This information is important for correct submission of encounter data.

Effective: January 1. 2015 there are four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”   Modifier -59 identifies services which normally are considered “bundled” in the main procedure.

Please make sure your billing staffs are aware of the coding modifier changes. The new HCPCS modifiers are collectively referred to as –X {EPSU} modifiers:

• XE- Separate Encounter- A service that is distinct because it occurred during a separate encounter.

• XS- Separate Structure- A service that is distinct because it was performed on a separate organ/structure.

• XP- Separate Practitioner- A service that is distinct because it was performed by a different practitioner.

• XU- Unusual Non-Overlapping Service- The use of a service that is distinct because it does not overlap usual components of the main service.

 

CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific - X {EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI Procedure-To-Procedure code pair may be identified as payable only with the - XE separate encounter modifier but not the -59 or other - X {EPSU} modifiers. The - X {EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.

CMS recommends the use of the new HCPCS modifiers in place of the -59 modifier whenever possible. SCAN also encourages all physicians, providers and billing staff to familiarize yourselves with these new HCPCS modifiers and implement them into your billing systems as directed by CMS. Effective starting date of service for use of HCPCS modifiers –X {EPSU} is January 1, 2015.

Encounter Data Submission Timetable—The timetable below shows the new submission requirements for Health Plans to CMS.  It also includes the risk score run dates.  The Encounter Data Team will notify you, in advance, when encounters are required to be sent to SCAN:
 

Risk Score Run	Dates of Service	Deadline for RAPS Submission*
2015 Initial	07/01/13--06/30/14	09/12/2014
2014 Final	01/01/13--12/31/13	01/31/2015
2015 Mid-Year	01/01/14--12/31/14	03/06/2015
2016 Initial	07/01/14--06/30/15	09/11/2015
2015 Final	01/01/14—12/31/14	01/31/2016

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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. The information presented herein is for general informational purposes only.