For those who have not had a chance to see the 2012 Advance Notice, released by CMS on Feb 18, 2011, there is guidance that CMS does not intend to change the standard HCC model as they had previously announced.  This means that for the non-ESRD models, i.e. the regular Community model, the same HCCs and hierarchy logic will be used for Dates of Service 2011 and 2012 payment.

It appears that the ESRD model will incorporate the new HCCs.  See the Advance Notice for more details.  PDF below.

Advance2012

The closest thing I have seen to an official recommendation from CMS on how long providers have to sign or amend records is this guidance from the 2008 Risk Training Guide.  While it mostly addresses claims submissions, I believe one could reasonably infer that 30 days is recommended to have the supporting documentation for that claim complete as well.

“What are the responsibilities of physicians and providers?

Physicians must report the ICD-9-CM diagnosis codes to the highest level of specificity and report these codes accurately. This requires accurate and complete medical record documentation. They are required to alert the MA organization of any erroneous data submitted and to follow the MA organization’s procedures for correcting erroneous data. Finally, they must report claims and encounter information in a timely manner, generally within 30 days of the date of service (or discharge for hospital inpatient facilities).”  (Page 3-19)

Keep in mind that for RADV audits, CMS will allow a provider to sign a CMS-generated attestation that an unsigned document is theirs.  But, only the rendering provider can sign the CMS attestation, partners or other doctors in the practice cannot.

Any confusion surrounding ICD-9 code 412 for Old Myocardial Infarction is likely related to CMS’ decision to delay the revision of the HCC model until 2012.  CMS had given guidance that the model revision would start in 2011, but the 2011 CY Announcement stated that this would be postponed until 2012.  So, therefore, ICD-9 412 still maps to HCC 83 for now.

Here is the proposed new model for 2012, new HCCs on the right are bolded, substantially revised HCCs are italicized.  In the document, you will see that HCC 83 gets changed to Respiratory Arrest.

2012 Model – pdf

For those of you who were not able to attend the 10.29.2010 national meeting on the CMS Plan to have MA plans submit Encounter Data, here is the presentation (pdf):

EncounterData National Meeting 10.29.2010 [click to view OR right-click to "save as" to computer]

The goal is to have MA plans ready to submit full encounter data  for professional and institutional claims by January 3, 2012.

Recently, I have had a couple questions about different kinds of non- face-to-face visits and whether ICD-9 codes could be used for risk adjustment.

I have never seen any guidance from CMS to suggest that telephone visits were acceptable sources of risk-adjustment data.  Similarly, it is not acceptable for a remote, third-party physician to review lab results or some other kind of clinical summary and then submit new ICD-9 codes that were not captured during a proper face to face encounter with the patient.

From page “6-6” of the 2008 CMS Risk Training Guide-

“Co-existing conditions include chronic, ongoing conditions such as diabetes (250.XX, HCCs 15-19), congestive heart failure (428.0, HCC 80), atrial fibrillation (427.31, HCC 92), chronic obstructive and pulmonary disease (496, HCC 108). These diseases are generally managed by ongoing medication and have the potential for acute exacerbations if not treated properly, particularly if the patient is experiencing other acute conditions. It is likely that these diagnoses would be part of a general overview of the patient’s health when treating co-existing conditions for all but the most minor of medical encounters.

Co-existing conditions also include ongoing conditions such as multiple sclerosis (340, HCC 72), hemiplegia (342.9X, HCC 100), rheumatoid arthritis (714.0, HCC 38) and Parkinson’s disease (332.0, HCC 73). Although they may not impact every minor healthcare episode, it is likely that patients having these conditions would have their general health status evaluated within a data reporting period, and these diagnoses would be documented and reportable at that time.”

From the CMS ICD-9-CM Coding Guidelines…

“J. Chronic diseases

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)

K. Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. “

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”.

**ADDENDUM – 9.21.2010 – add Universal American to this list – 291, 814- Thanks, Matt

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.