CSSC finally uploaded the long awaited guides for Encounter Data Submission to their website last Friday.
Here are links to the files (pdf):
EDCompanionGuide_837P – Professional
EDCompanionGuide_837I – Institutional
Or, if you want to grab them from the CSSC website: Use this link:
** 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.
Beginning with 2012 Dates of Service, CMS expects MA plans to submit ICD-9 codes via full encounter data on a monthly basis rather than quarterly. To date, CMS has issued guidance that claims (i.e. encounter data) must be passed on to Medicare within 12 months of the Date of Service. CMS is suggesting that this 12 month deadline will also apply to ICD-9 data gathered from retro chart reviews as well, although you can tell from the guidance that CMS has not yet ruled on this definitely.
For your reference, pdf files – click to download.
Scan HealthPlan Encounter Data FAQ
CMS Full Encounter Data QAs 10.29.2010
Summary Notes.Chart Reviews.02-16-11 (From CMS Chart Review Work Group – www.tarsc.info)
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 2012 Announcement mentions an update to the physician specialty type list of acceptable sources of physician risk adjustment data.
These changes are effective with dates of service from January 1, 2010.
Added:
(9) Interventional Pain Management (IPM)
(15) Speech Language Pathologist
(17) Hospice And Palliative Care
(27) Geriatric Psychiatry
Deleted:
(70) Multispecialty Group
PDF document from CSSC Operations website: Risk Adjustment CMS Specialty Types CSSC
The RAPS file format will be modified on Jan 1, 2012 to create more room in the diagnosis fields to accommodate ICD-10 codes that can be up to 7 alphanumeric characters. Also, a new field will be added to flag whether the diagnosis is an ICD-9 or ICD-10 code. While ICD-10 codes are not expected in RAPS files until the October 1, 2013 ICD-10 implementation date, the RAPS file is getting ready in advance of the changeover, and the ICD-9 flag on ICD-9 diagnosis submitted until October 1, 2013 will be helpful for the look backs and risk score calculations.
From the 2012 Advance Notice….p. 27-28
“Effective January 1, 2012, CMS is modifying the format of the RAPS file currently used in the risk adjustment data collection and storage process, to accommodate the ICD-10 mandate.
Two changes will be made to the file. First, the Diagnosis field currently using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), 5 character codes, will be changed to 7 character codes to accommodate the expanded ICD-10 clinical modification (CM) codes. Second, there will be a new field added to the RAPS file. This field will indicate which version of the diagnosis codes, revision 9 or revision 10, is stored in the diagnosis field. While the change from ICD-9 to ICD-10 will be a complete cutover on October 1, 2013, the diagnosis type indicator is required to allow the processing of adjustments to previously submitted data.”
From the July 2010 User Guide:
There are occasions where plans will need to delete diagnosis clusters. Here are some reasons for deleting the clusters.
1) Diagnosis clusters submitted erroneously (e.g., data from an interim bill was submitted for hospital inpatient, type of bill 112 / 113. When TOB 114 has been received.), therefore, plans should correct previously submitted claim with the corrected diagnosis clusters.
2) Incorrect HIC number used for submission on a beneficiary’s claims
3) An error in a diagnosis cluster field (i.e., “Provider Type,” “Dates of Service,” “Diagnosis Code”)
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.
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.
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.
