Here are the top Medicare Advantage plans by Part C enrollment.

Data from cms website: 07/2010 enrollment data: http://www.cms.gov/MCRAdvPartDEnrolData/EP/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=2&sortOrder=descending&itemID=CMS1237234&intNumPerPage=10

Did not count Part D plans, sorted by “Parent Organization”.

Nursing notes from LPNs or RNs  are not acceptable sources for risk-adjustment diagnoses.

The following nursing specialties are recognized as acceptable provider/specialty types:

- Certified Nurse Midwife

- Certified Clinical Nurse Specialist

- Certified Registered Nurse anesthetist

- Nurse Practitioner

For those of you who have not already read the CMS Impact study of ICD-10 on the Medicare space (July, 2009 by Nobilis), I wanted to present the Medicare Advantage/ risk adjustment related sections.

Download as .pdf file   ICD10_Impact_on_Risk_Adjustment

One of the most frequent questions to this blog is whether or not health plans can abstract ICD-9 codes from diagnostic radiology reports for risk-adjustment reporting.  The public guidance from CMS has been that such sources, whether institutional or professional-component are not acceptable for risk-adjustment.

“The following CPT codes indicate diagnostic radiology and other diagnoses that should not be submitted as risk adjustment data: 70010 through 76999 and 78000 through 78999″

“It is important for MA organizations to note that regardless of the type of diagnostic radiology bill (outpatient department or physician component), the services are not acceptable for risk adjustment.”

“CMS will not accept medical records for diagnostic radiology regardless of the type of bill (outpatient department or physician component) as support for data submission of a diagnosis. CMS recommends plans locate the medical record from the referring physician and determine if the diagnosis in question is based on the physician’s documentation in the medial record.”

*Quotes extracted from 2008 Risk Training guide and Feb 2008 CMS User Group Notes.

From yesterday’s CMS April 5, 2011 Announcement, pg. 2:

“Part C Risk Adjustment Model. Based on our interpretation of Congressional intent regarding changes in Part C payment methodology, CMS will not implement the new CMS-HCC and CMS-HCC ESRD dialysis risk adjustment models or the recalibrated frailty factors in 2011. CMS will implement these new models in 2012. To reference the factors in the CMS-HCC risk adjustment model that will be used in 2011, see the 2009 Rate Announcement (published in April 2008). To reference the factors in the CMS-HCC ESRD risk adjustment model that will be used in 2011, see the 2008 Rate Announcement (published in April 2007).”

Link to 2011 Announcement:

http://www.cms.gov/MedicareAdvtgSpecRateStats/AD/list.asp#TopOfPage

I am hearing from several of my readers that the 2011 HCC model codes will implemented starting payment year 2011.  This means that the new code crosswalk (to be finalized April 5th by CMS) will be implemented during the following dates of service windows.  The January 2011 preliminary payment rates will be set by the July, 2009 to June, 2010 12 month dates of service window using the new codes.  The July 2011 payment rates will be set by dates of service in CY2010 using the new codes.

I did a quick comparison of the ICD9s in the current  2010 Payment Year HCC-ICD9 crosswalk to the ICD9s mapped to the preliminary release of the 2011 CMS and found about 250 “newly added” ICD-9 codes that are not in previous models.  Again, this is a prelim release, so treat this file as an FYI that may change.  On tab 2 of the excel are the 100 or so ICD9s slated for deletion for PY2011.  Say goodbye to everyone’s favorite “412 Old Myocardial Infarction”.

2011_HCC_changed_ICD9s(PRELIM) XLS (excel)

Been getting lots of questions lately on which ICD-9 code sets are valid for a particular payment year.  CMS issued guidance on this in their 2009 Advance Notice.

“Starting with payment year 2009, RAPS will only accept valid ICD-9-CM codes for two fiscal years — the fiscal year that begins prior to the payment year and the fiscal year that begins during the payment year — for the CMS-HCC, ESRD, and RxHCC risk adjustment models. For example, for diagnoses codes to be used in 2009 final payment, i.e., for diagnoses from service dates between January 1, 2008 and December 31, 2008, RAPS will only accept codes that are valid for Fiscal Year 2008 and Fiscal Year 2009. (Please note that for the initial risk score run for payment year 2009, CMS will use valid diagnosis codes from FY 2007 and FY 2008 — services dates between July 1, 2007 and June 30, 2008.)”

Pages from Advance2009 PDF

Wow, after looking at the 2011 Advance Notice and the prelim 3,090 ICD-9 codes in the 2011 HCC model it is apparent that there are several new HCCs for 2011.  The diabetes group is curtailed from 5 HCCs down to 3.  Dementia HCCs were added.  Pressure Ulcer HCCs (4 of them) were added.

Here are some prelim files for your information – final 2011 model to be finalized in April.

CMS-HCC Model 2011 (PDF – shows HCC revisions)

2011_HCC_ICD9 (XLS – shows 3090 ICD9s mapped to HCC, second tab is the 87 HCCs in the 2011 model- I created this file by crosswalking the 3,090 ICD9s in the prelim model to their English descriptions for 2010 ICD-9 codes.  The second tab is an excel I extracted from the 2011 Advance Notice pdf.

As you have heard, the CMS-HCC Model will change slightly in 2011 with basically some re-organization of ICD-9s into different categories.

Here is a link to the first draft of the codes for 2011.  The final version is expected April, 2010.  This link is to just a numeric crosswalk, I will try to compile a complete file in English in the next few days.