** See new comments below.

Original Post
A common question for me is whether or not dentists qualify as acceptable specialty types for risk adjustment. The answer is that only a subset of dentists – namely, Oral Surgeons (CMS specialty type 19) are acceptable sub-specialists from within the dentistry field.

Oral Surgeons are most typically dentists (DDS or DMD) with advanced training in oral-maxillofacial surgery (OMFS).

Specialists in this field handle all things related to head, skull, neck, jaw, teeth whether it be cleft palate reconstruction, facial reconstruction after trauma, dental implants or cancer-related head and neck surgeries.

So, only dentists who designate themselves in the documentation as providers in Oral Surgery or Oral Maxillofacial Surgery are acceptable dental sub-specialists from which you may obtain ICD-9 codes for risk adjustment.

** Addendum 7/21/2011.
Please see Comment #1 for correction. Thanks mistmi01! Oral Surgeons will map to CMS specialty code 19 (maps to NUCC Taxonomy code 1223S0112X), while standard Dentists must designate themselves as CMS specialty code 99 “Unknown Physician Specialty” when they apply for Medicare privileges. So, all dentists are acceptable sources for risk adjustment. Health plans may use NUCC taxonomy codes to distinguish dentists from oral surgeons. The NUCC code for a standard dentist is 122300000X. Oral Surgeons treat a broader number of conditions that are in the risk adjustment model.

Q: Does a health plan need the facility’s (clinic) permission to add a chronic condition to a claim when the evidence of evaluation and treatment is found in the documentation? Our problem is the very rural areas are coders who do not know anything about risk adjustment and are constantly disagreeing with out findings because they think you ONLY code the reason for the visit no matter what information I give them regarding the importance of coding chronic conditions when addressed/assessed and treated. Any guidance you can offer would be a great help!

A: A health plan does not need a provider’s permission to submit documented ICD-9-CM codes to the RAPS database. Any documented chronic or acute condition that a certified coder could abstract from the proper face-to-face documentation (i.e. signed, dated, credentialed by acceptable specialty type) may be submitted for risk adjustment purposes. All of the chart auditing vendors and any coders working for a plan may abstract and code diagnoses that are properly documented and submit to the plan or submit to CMS on behalf of the plan.

Ideally, these additional codes would be submitted on claims in the first place for ease of processing, but you may submit ICD-9-CM codes to RAPS that have been collected in other means, such as a superbill, chart audit, etc.

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.

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

CMS announced in the Oct 22, 2009 Fed Register that they plan to audit 110 MA plans total during the two year period of 2010-2011. All plans will have a 12-week deadline to submit the one best medical record to substantiate an HCC. Typically 700 HCCs will need to be validated on an approximate sample size of 200 patients. Discrepancies will be extrapolated on the plan level for that discrepant HCC rather than as formerly done on the individual beneficiary level.

I have fielded several questions this week about unusual provider types – do not hesitate to email me with questions (see About page for email link).

MBBS- is an M.D. Degree conferred by medical schools in the United Kingdom as well as other English speaking countries. Should be treated as Physician Provider Type.

LPCC (Licensed professional clinical counselor) – most LPCCs are psychologists which maps to CMS Specialty 62 Psychologist and is acceptable.

I get frequent questions about whether it is acceptable to pull an ICD-9 diagnosis from a Problem list.  I usually urge caution because problem lists in EMRs tend to be either cut and pasted or automatically generated, both methods can perpetuate errors.  Also, problem lists in paper charts are often devoid of evaluation and management updates that are signed by a provider on a specific date, in other words, are less likely to meet the criteria below. CMS has given guidance that ICD-9s can be used from the problem list only if it shows evaluation and management for that date of service and is signed by the provider.  Here is the exact guidance from the 2008 Training Guide, pg. 7-17:

“Guidance for Problem Lists

All the software/claims analysis HCC vendors have in common that they can at least find HCCs that have disappeared from one data period to the next. Make sure that they are then imposing the CMS-HCC hierarchy on the proposed “fall-offs” to recapture, so that there is an intelligent suggestion of which ICD9 codes to look for in audits.  For example, if an HCC 19 (diabetes no complications) falls off from the claims data but has been replaced by an HCC 15 (diabetes with renal), then there is no need to pursue the HCC 19 that disappeared as it has been replaced by a more valued ICD9 code in the hierarchy. Also, make sure the vendors have accounted for the overlapping data collection periods and that the software recognizes that it is not sufficient just to capture an HCC “once in 2007″ and “once in 2008″ as there would be a gap in reimbursement if the HCC code is captured more than 12-18 months apart.

It sounds like about 60 Medicare Advantage plans will be contacted to undergo a RADV – Risk Adjustment Data validation audit for CY 2006. My understanding is that plans selected for audit should have been contacted by now, as letters went out late Nov/early Dec.

In addition to the RADV excerpt in the entry below, here is the CMS Data Validation Pilot study again that shows common reasons why plans fail audits.

Here is the relevent chapter from the CMS training guide (12/07) on the Risk Adjustment Data Validation audits: RADV. I anticipate that the CMS risk training guide will be updated soon, will post that when available.