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 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”)

Here is the RAPS submission schedule through DOS 2013 from the CSSC Operations Website.
PDF

raps-submission-timetable_030910

Website
CSSC Operations

Here is a direct link to the future RAPS submission deadlines for MA plans to submit ICD-9 data to CMS for inclusion in the RAPS database. link

The sweep of the RAPS data with dates of service 01/01/07 – 12/31/07 occurred on February 13, 2009. RAPS data accepted by 5:00 pm EST Friday, February 13th are included.

CCC Record: (Patient Detail|Diagnosis Record)

501 – (Informational Edit) Valid diagnosis but not a relevant diagnosis for risk adjustment during this service period.  - 62%

410 – Beneficiary is not enrolled in Plan on or after Service From Date. – 10.5%

408 – Service From date is not within MA enrollment period. – 9.4%

409 – Service Through date is not within MA enrollment period.  -  8.65%

502 – Diagnosis cluster was accepted but not stored. A diagnosis cluster with the same attributes is already stored in the RAPS database. –  2.94%

When submitting valued ICD-9 codes to CMS, it is fine to submit duplicate HCCs throughout the course of the year.  CMS does prefer RAPS data to come into the FERAS system somewhat evenly throughout the year, rather then just right before the March or September Sweeps deadlines.

While it is perfectly fine to submit duplicate HCCs through the year and let the system sort them out, it is not ok to submit “duplicate diagnosis clusters”, which is defined by an instance of “Provider Type + Dates of Service + ICD-9 code”.  In other words, do not submit “401.1 on 10/10/08″ more than once.

So, each MA plan should have a robust system in place (i.e. a good IT person), to filter out or prevent the duplicates.  CMS welcomes smaller “test” files of up to 3,000 records (repetitions of the Detail Level or CCC records) for plans to check to make sure that the test file does not contain duplications.

Should your auditors find that erroneous ICD-9 data had been submitted to RAPS, your IT department will have to resubmit the same “diagnosis cluster” to RAPS this time with a “D” or delete code to remove it from the RAPS database. See deletions.

A diagnosis cluster for a patient is the ICD9, From Date, Through Date, Provider Type.

The RAPS database stores “unique” diagnosis clusters, i.e. those that are not duplicates.  Duplicate diagnosis clusters trigger the 502 error “Already stored in RAPS”.