HCC Blog by Caridad

Have you ever wondered what career opportunities are available with the Federal Government in the Office of the Inspector General? Well here is a link to the website to check that out from time to time! OIG Careers USAJOBS.GOV https://oig.hhs.gov/careers/

 Here are some highlights from the press release: The government alleged that BioTelemetry — with the knowledge of then senior management — diverted certain federal beneficiaries’ ECG Data to India when the domestic workflow became backlogged. “Federal health care beneficiaries deserve care, including remote cardiac monitoring, that complies with federal law and is provided by qualified clinical personnel,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “Today’s settlement reminds all providers that they must observe those standards and reflects the department’s commitment to pursue knowing violations of federal health care program requirements.”  The United States further alleged that most of the offshore technicians tasked with reviewing ECG Data for federal healthcare program beneficiaries did not have the basic qualifications to perform the tests in question.  In connection with the settlement, BioTe...

This Risk Adjustment 101 program is designed for individuals who are either new to the risk adjustment process or desire a refresher of the basics.  The primary audience for this program includes:  Medicare Advantage (MA) and Medicare Advantage-Prescription Drug (MA-PD) organizations; Regional and Employer Group Health plans;  Demonstration projects;  Program of All-Inclusive Care for the Elderly (PACE) organizations;  Specialty plans; and Third party submitters contracted to submit data on behalf of risk adjustment organizations.  This is good for us risk adjustment coders to have a knowledge about this, but it is mostly used by the health plans.  https://www.csscoperations.com/internet/csscw3_files.nsf/F/CSSC2013_RA101ParticipantGuide_5CR_081513.pdf/$FILE/2013_RA101ParticipantGuide_5CR_081513.pdf

I was wondering what codes for transplant status actually risk adjust or have associated Risk Adjustment Factor (RAF), here's a list: Transplanted organs Z94.0 Kidney transplant status Z94.1 Heart transplant status Z94.2 Lung transplant status Z94.3 Heart and lungs transplant status Z94.4 Liver transplant status Other Z94.81 Bone marrow transplant status Z94.82 Intestine transplant status Z94.83 Pancreas transplant status Z94.84 Stem cells transplant status Kidney transplant is not included. These 'Z' codes communicate the status of a transplant. The only documentation needed is the provider's documentation of presence or history of there having been a transplant.  These codes belong in HCC 186 Major Organ Transplant or Replacement Status 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 ...

This is a link to the CMS site that has the list of HCC risk adjustment codes for this year and previous years.   https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats/risk-adjustors

On the CMS web page, there is a list of   Medicare Risk Adjustment Eligible CPT/HCPCS Codes Here is the link to download those:  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.

  The Office of Inspector General's (OIG) work plan is posted at this link.  In the gray area, on the left, there is a  "What's New" box. At the bottom there is a link for "Recently completed and published reports". This shows you what they posted each month to date. I look for the ones that start with "Medicare Advantage Compliant Audits..." as those detail their audits of HCC codes for the MA organizations. Also on this page, under the title "Work Plan" there are links for 'Recently Added', "Active Work Plan Items', "Work Plan Archive'. Click on those for more information.  https://oig.hhs.gov/reports-and-publications/workplan/index.asp 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, reg...

Charlson comorbidity The Charlson comorbidity index predicts the one-year mortality for a patient who may have a range of comorbid conditions, such as heart disease , AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score of 1, 2, 3, or 6, depending on the risk of dying associated with each one. http://mchp-appserv.cpe.umanitoba.ca/concept/Charlson%20Comorbidities%20-%20Coding%20Algorithms%20for%20ICD-9-CM%20and%20ICD-10.pdf There are also online calculators that the provider can consider are available at the Medical Agorithms site.  The updated Charlson Comorbidities Index is found at Medical Algorithms site:   https://www.medicalalgorithms.com/charlson-comorbidity-index 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 l...

 I came across this Summary Information on the 2019 Benefit Year HHS Risk Adjustment Data Validation Results, released February 25, 2022.  https://www.cms.gov/files/document/2019-radv-results-memoclean2022-02-23.pdf Page two mentions the  Super Hierarchical Condition Category (Super HCC) group See the 2020 HHS-RADV Amendments Rule, 85 FR at 76984 - 76990 Scrolling down to page 10 of the document, we find  Appendix D: 2019 Benefit Year HHS-RADV Failure Rate Group Definitions.  Here the Super HCC and HCC categories are shown along side the Failure Rate Group (low, medium and high) Amendments to this document include: Amendments to the HHS-Operated Risk Adjustment Data Validation (HHS-RADV) Under the Patient Protection and Affordable Care Act's HHS-Operated Risk Adjustment Program Along side this document there is  https://www.federalregister.gov/documents/2020/12/01/2020-26338/amendments-to-the-hhs-operated-risk-adjustment-data-validation-hhs-radv-und...

 The Acceptable Physician Specialty Types for PY 2022 risk adjustment are found at the link below. Be sure to download the document for easy reference. https://www.csscoperations.com/internet/csscw3.nsf/DIDC/HSEK7AHN1H~Encounter%20and%20Risk%20Adjustment%20Program%20(Part%20C)~References    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.

 Sharing this is a list of sources I use when doing research. Authoritative Resources for ICD-10 1.        International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) a.        ICD-10-CM Official Guidelines 2.        Centers for Medicare and Medicaid Services (CMS) Manuals Transmittals 3.        Risk Adjustment Documentation & Coding, Second Edition, Sheri Poe Bernard 4.        Acdis Outpatient Pocket Guide 5.        AHA Coding Clinic for ICD-10-CM 6.    Medical Abbreviations.com 7.    UCSD Health Library 8.    Psychiatry online DSM Library   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 accur...

CMS conducts annual RADV audits to ensure risk-adjusted payment (HCC) integrity and accuracy. The purpose is to identify any payment errors by having the MA organizations and their corresponding providers to submit specific requested medical records to validate the risk adjustment data or HCCs. So if a specific claim is included in the RADV audit, and it has a code for say, Diabetes Type 2 E11.9, they will review the chart note to see if it was appropriately documented. An errors can result in funds being returned to CMS. This document list the specifics around RADV audits. The latest RADV Medical Record Guidance For auditing commencing after 01/10/2020, Version 2.0 https://cms.gov/files/document/medical-record-reviewer-guidance-january-2020.pdf https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/Coders_Guidance.pdf RADV Medical Record Reviewer Guidance ========================= Prior guidance on audits commencing after 09/27/2017 'Contract-Level Risk Adjustment...

CMS has released their Advanced Notice for CY 2023. Highlights for risk adjustment include: Section G. CMS-HCC Risk Adjustment Model for CY 2023          page 42 For CY 2023, CMS will continue to calculate 100 percent of the risk score using the 2020 CMSHCC model, which we began phasing in with CY 2020 payment as described in Part I of the CY 43 2020 Advance Notice.10 The 2020 CMS-HCC model complies with the revisions to the risk adjustment for MA payments required by section 1853(a)(1)(I) of the Act, as amended by the 21st Century Cures Act.  Section M. Sources of Diagnoses for Risk Score Calculation for CY 2023 Page 67 then Attachment III, Section A. RxHCC Risk Adjustment Model     Page 68   Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (cms.gov) 159 pages

An audit summary report from the Office of Inspector General (OIG) Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan Submitted to CMS Date of report 02/03/2022 For this audit the OIG reviewed the diagnosis codes submitted by SCAN Health Plan from claims from 2015. Yes, the review was on claims for the year 2015. Highlights from the report include: Sample set was 200 enrollees. Per the OIG, 164 HCCs were not validated and resulted in overpayments The OIG estimated that SCAN received at least $54.3 million in net overpayments for 2015. SCAN disagreed with their findings and after review the OIG revised the number of un-validated HCCs and changed the recommended refund amount due by SCAN.  The link to the report is found: Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan (Contract H5425) Submitted to CMS (hhs.gov) https://oig.hhs.gov/oas/reports/region7/71701169.asp Disclaimer: This guidance is to be used for an easy reference; the...

I am sharing an insightful article from Libman Education  https://libmaneducation.com/ written By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA entitled: Coding: What Documentation Should I Use? here is a links to their article: https://libmaneducation.com/coding-what-documentation-should-i-use Her blog post covers information for discussion among coders on whether we should code from the history list, problem list, or medication list. The 3rd quarter 2021 Coding Clinic offered their insight as well. Other articles from their newsletter can be found on this page:   https://libmaneducation.com/whatsnew/ Newsletters > Articles  Great food for thought. 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...