Remember, CMS gives you all the info you need in their monthly Model Output Report to determine which HCCs have been captured in the prior period and have not been yet reported for the current period.  Your IT department can construct a list for you by comparing older MORs to newer ones to see which HCCs are no longer reported.  After mining all of your current ICD-9 claims data and sending in your most current RAPS files – if those HCCs are still missing, it is a great opportunity to prompt your providers to either get that patient back in clinic for followup or to search their prior clinic record for evidence of documentation that would support that missing HCC.  The providers can report those previously unreported ICD-9 codes to the plan with the minimal data set needed for RAPS or can submit another HCFA-1500 provided that the plan has a mechanism to ensure that they can distinguish between new HCFA-1500s that demand payment or merely are “repeat HCFA 1500s” that just carry risk information to retroactively report ICD-9 codes that did not get reported on the original claim.

When your auditors are reviewing charts for ICD-9 codes that were not submitted into the original claims data, make sure they are collecting enough information to help your IT department create the RAPS file you will submit to CMS.  This minimum data set includes:

1. Provider Type:

01 Hospital Inpatient – Principal Diagnosis
02 Hospital Inpatient – Other Diagnosis
10 Hospital Outpatient
20 Physician

2. HIC (Health Insurance Claim Number – their Soc Sec # plus the letter suffix)

3. Service From Date (format YYYMMDD, example: 20071201)

4. Service Through Date- this can be left blank for Hospital Outpatient and Physician data as the CMS computer will automatically fill it in for those instances

5. ICD9 diagnosis code without the period, so 272.0 would be “2720″ as the decimal will be implied

Here are the related pages from the latest CMS Risk Training Guide: Minimum Data

Don’t forget that the final deadline for fiscal year 2006 is Jan 31.  The initial submission deadline for 2007 is March 7.  Final deadline for 2007 will be Jan, 2009.

Keep in mind that CMS hopes that plans will eventually submit about 25% of their annual data on a quarterly basis.  The goal is for all plans to submit data evenly through the year, rather than all data right before a deadline.