HCC Blog by Caridad

The Office of Inspector General (OIG) released a publication entitled,  Medicare Advantage Industry Segment-Specific Compliance Program Guidance, February 2026. It describes risk areas in the Medicare Advantage Organization (MAO) program, recommendations to mitigate those risks and information to consider in compliance programs.  For risk adjustment, take a look at Section II. Compliance Risk Areas and Recommendations for Mitigation, section C. Risk Adjustment OIG has examined MAOs reporting diagnoses based solely on chart reviews or health risk assessments (HRAs) and providing no other records in the encounter data that enrollees received services for the diagnoses. "These resources are not one-size-fits-all, comprehensive, or inclusive of all compliance considerations or risks. They are not binding on any individual or entity. Of note, OIG uses the word “should” in the Medicare Advantage ICPG and GCPG to present voluntary, nonbinding guidance. This means that the docume...

  Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2025, 2026, and 2027

Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) Severe Sepsis Present Data Element Version 5.14a Questions and Answers Effective for July 1, 2023, through December 31, 2023 "Participants will be able to understand and interpret the guidance in Version 5.14a, effective for July 1, 2023, through December31, 2023 discharges, of the specifications manual, specific to the Severe Sepsis Present data element, to ensure successful reporting for the SEP-1 measure for the Hospital Inpatient Quality Reporting Program." A few highlights from the document include: To establish the presence of severe sepsis by clinical criteria , all three clinical criteria (a, b, and c) must be met within six hours of each other. The three clinical criteria do not need to be documented in any particular order.  a. Documentation of an infection  b. Two or more manifestations of systemic infection according to the Systemic Inflammatory Response Syndrome (SIRS) criteria  c. Organ dy...

The Medicare Program Integrity Manual contains the guidance around signature requirements.  They are  found in chapter 3. 3.3.2.4 - Signature Requirements  This material was also covered in the Part AB November 2025 webinar by Noridian entitled: Signature Requirements 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.

In ICD-10-CM code book, osteomyelitis, M86, is subdivided into these body areas:       shoulder      humerus      radius and ulna      hand      femur      tibia and fibula      ankle and foot      multiple sites then each is further subdivided by:   acuity (acute, subacute or chronic)  and  laterality (left or right) Use additional code (B95-B97) to identify infectious agent and any major osseous defect, if applicable (M89.7-) 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 h...

Depending on the reason a patient is being seen after a fall, here are two scenarios to consider.  Let's look at these two diagnoses - Fall, initial encounter vs. history of falls.  If clinician uses the diagnosis of "Fall, initial encounter"  then they need to add the date of the fall to the chart note. When using the code of W19.XXXA, a Date of Injury must be provided. Add the date of injury in the claim information record. As an example, this diagnosis can be used for worker's compensation visits.   Or, if appropriate, clinician can also consider using the diagnosis of 'history of falls' Z91.81. With this code, no date is needed. This can be used with quality reporting. Clinicians documentation of the reason for the fall will help with code selection. 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 compl...

  Dementia ICD-10-CM classifies dementia on the basis of: etiology, severity and associated behavioral disturbances.  Etiology  refers to the type of dementia. This can include:      Vascular dementia F01      Dementia in other diseases classified elsewhere F02      Unspecified dementia F03 Severity  includes mild, moderate and severe:                 Mild - Clearly evident functional impact on daily life, affecting mainly instrumental activities. No longer fully independent; requires occasional assistance with ADLs.                 Moderate - Extensive functional impact on daily life with impairment in basic activities. No longer independent; requires frequent assistance with ADLs.                 Sev...

For this diagnosis of diabetes with skin complications, the relationship between the two conditions must be stated by the provider in their documentation. There is not presumed relationship as with some other diabetes diagnosis. This can include: cellulitis and onychomycosis (fingernails and/or toenails) as well as other provider stated conditions. Codes include: E10.628 Type 1 diabetes mellitus with other skin complications E11.628 Type 2 diabetes mellitus with other skin complications E13.628 Other specified diabetes mellitus with other skin complications 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 ...

Here is the list of Acceptable Physician Specialty Types for Risk Adjustment Data Submission 2024 Payment Year  https://www.csscoperations.com/internet/csscw3_files.nsf/F2/Acceptable%20Physician%20Specialty%20Types%20PY2024%20508.pdf/$FILE/Acceptable%20Physician%20Specialty%20Types%20PY2024%20508.pdf

 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...

  Congressional Testimony: The Honorable Christi A. Grimm, Inspector General for the U.S. Department of Health and Human Services, testifies before the United States House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations: "Examining How Improper Payments Cost Taxpayers Billions and Weaken Medicare and Medicaid.”   Watch the Testimony Video  https://www.youtube.com/watch?v=UpquPVaQrH8 Read the Testimony  https://oig.hhs.gov/documents/testimony/9865/ig-grimm-testimony-04162024.pdf Interesting time stamps: 36:07 opening statement Krisiti Grimm on Improper payments 46:45 Opening statement Dr. Chernew, chair of Medicare Payment Advisory Commission (MedPAC) 55:02 Mr. Griffith statements and question to Ms. Grimm 55:30 Krisiti Grimm response 57:41 question on how medicare advantage payments are calculated, enrollee risk score calculations and calculation of coverage payments 1:00:43 question of Ms. Grimm – reporting requirements ...

  Learn about the financial relationships that doctors and other healthcare providers have with drug and medical device companies. 2022 data is available

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.