HCC Blog by Caridad

OIG shared this 48 page Toolkit To Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes released December 2023. What Is the Toolkit?  "This toolkit is meant to be a practical, hands-on device that will help MA organizations improve the accuracy of their submitted diagnoses that are at high risk for being miscoded." It includes a list of high-risk diagnosis codes that are consistently submitted to CMS.  This specifically helps the MA plans to adapt actual programming codes to query its internal data systems to accurately identity the enrollees in these high-risk groups. There is programming language included as well. https://oig.hhs.gov/oas/reports/region7/72301213.pdf

 Here is a great article about the "Pill-in-the-Pocket" approach to treating atrial fibrillation. Enjoy [Peer-Reviewed, Web Publication] Feiger, D. Andereck, J. (2020, Nov 2). A “Pill-in-the-Pocket” approach to paroxysmal atrial fibrillation. [NUEM Blog. Expert Commentary by Patil, K]. Retrieved from http://www.nuemblog.com/blog/pill-in-pocket. https://www.nuemblog.com/blog/pill-in-pocket

Here is an online tool to help with finding ICD-11 codes.  It is the 'ICD-11 Coding Tool Mortality and Morbidity Statistics (MMS) 2023-01'. https://icd.who.int/ct11/icd11_mms/en/release Type in a diagnosis term and the system will show you the code. For example, I typed in 'type 2 diabetes', the code is 5A11. There are some other options in the list as well: This can help us become more familiar with this code set.  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.

 Here is a post from the National Cancer Institute, SEER Training Modules, on International Classification of Diseases for Oncology (ICD-O), third edition, morphology coding. By visiting the webpage you can read about coding for morphology. https://training.seer.cancer.gov/coding/guidelines/morphology.html Also, separately, the ICD-O by World Health Organization, has been used for nearly 35 years, principally in tumor or cancer registries, for coding the site (topography) and the histology (morphology) of the neoplasm, usually obtained from a pathology report. If you want to take a look check out:    https://apps.who.int/iris/bitstream/handle/10665/96612/9789241548496_eng.pdf    if the link doesn't work, enter ICD-O in your browser search engine. The differences between ICD-O and ICD-10 are on page 4 of the pdf. The snip below is on coding for Morphology. https://training.seer.cancer.gov/coding/guidelines/morphology.html Disclaimer: This guidance is to be used f...

  CMS-Hierarchical Condition Categories (CMS-HCC) Risk Adjustment Model (Non-PACE) In the proposed CY 2024 Advance Notice, on page 3, there is a proposed announcement that the risk scores will be calculated as a blend of 67% of the risk scores calculated with the current model (the 2020 model) and 33% of the risk scores calculated with the updated model (the 2024 model). For CY 2025, they expect risk scores to be calculated as a blend of 33% of the risk scores calculated with the 2020 model and 67% of the risk scores calculated with the 2024 model, and for CY 2026 , they   expect 100% of the risk scores to be calculated with the 2024 model. Link to the document:  Announcement March 31 2023 file:///C:/Users/cjtrujillo/Downloads/2024%20Rate%20Announcement%20033123_FINAL508.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 a...

  CMS published Inpatient provider file by hospital for inpatient care in traditional Medicare patients. This contains "Information on hospital discharges from Original Medicare (fee-for-service) Part A (Hospital Insurance) beneficiaries by Inpatient Prospective Payment System (IPPS) hospitals; aggregated by provider." In the search bar, locate the name of the facility you are interested in. Currently, data from 2021 and previous years is available.  Hit the blue 'Export' button to download the CVS file for the facility you are interested in.  The last column of the report has the Beneficiaries Average Risk Score .  Save this file to your computer.  https://data.cms.gov/provider-summary-by-type-of-service/medicare-inpatient-hospitals/medicare-inpatient-hospitals-by-provider/data

These are some links to resources on the RADV program available from CMS.  From the main page:   Research, Statistics, Data & Systems>  Medicare Risk Adjustment Data Validation Program > Resources https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-risk-adjustment-data-validation-program/resources Scroll down this page to Downloads. This is where you will find the Medical Record Review Guidance 2020 document.  Here is the direct link:   https://www.cms.gov/files/document/medical-record-reviewer-guidance-january-2020.pdf-0 Happy reading! 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 re...

  Highlights for me:  Page 65-115 page 163 Timely Follow-up After Acute Exacerbations of Chronic Conditions (Part C) page 184 HCC categories (aka Disease Coefficients) page 195 Table VIII-4. 2024 CMS-HCC Model with Disease Hierarchies https://www.cms.gov/files/document/2024-announcement-pdf.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.

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), released the Calendar Year (CY) 2024 Medicare Advantage (MA) and Part D Rate Announcement. The 2024 Rate Announcement can be viewed at   https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents  and selecting “2024 Announcement.” https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents 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 d...

 SUBJECT: Advance Notice of Methodological Changes for Calendar Year (CY) 2024 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies Page 126 has the Disease Coefficients by category with many changes. You can compare the categories against last year's list to see the differences.  https://www.cms.gov/files/document/2024-advance-notice.pdf

 ICD-10-CM Official Guidelines for Coding and Reporting FY 2023 -- UPDATED April 1, 2023  (October 1, 2022 - September 30, 2023) In the document, narrative changes appear in bold text Items underlined have been moved within the guidelines since the FY 2022 version. Italics are used to indicate revisions to heading changes. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/April-1-2023-Update/ICD-10-CM-Guidelines-April%201,%20FY2023.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.

From the OIG latest newsletter, they shared where we can find information on their latest workplans. " The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections" they do this " In order to enhance transparency around OIG's continuous work planning efforts, OIG will update its Work Plan website month."   Here is a snip of their recently added items:  Some of these are focused on Medicare & Medicare Advantage organizations. To see the full list visit their site: https://oig.hhs.gov/reports-and-publications/workplan/updates.asp