Risk Adjustment User Group March 2008

Welcome to the March User Group Introduction Payment Process Operations Update Data Validation Technical Assistance Update Questions and Answers Closing

INTRODUCTION

INTRODUCTION User Group Process All attendees must pre-register It is only necessary to register once Retain unique PIN for all sessions Session will last for one hour Session slides will be available by the Tuesday before the session Panel will answer questions during the Q&A portion of the session

INTRODUCTION Based on competing priorities and responsibilities at CMS, the monthly Risk Adjustment User Group Q & A and Notes documents will be posted in the near future. Please continue to review the CSSC Operations website for updates to this information.

PAYMENT PROCESS

PAYMENT PROCESS Final ESRD payments for 2005 will be in the April 2008 payment ESRD payments for 2006 were issued in August 2007 Part C and Part D risk adjustment updates: - Mid-year 2008 will take place in the July payment - 2008 Final will take place in the August payment.

DATA VALIDATION

DATA VALIDATION UPDATES Calendar Year 2007 Calendar Year 2006

OPERATIONS UPDATES

CSSC OPERATIONS On the monthly reports, what is the difference between stored clusters and model stored clusters? Stored The Risk Adjustment Database stores all unique, valid diagnosis clusters. Includes diagnosis codes that are not used in the risk adjustment model.

CSSC Operations Model Stored Only includes relevant diagnosis clusters identified in the CMS HCC model. They are used in the risk adjustment model.

CMS Operations (Data Submission) History & Physical (H & P) Within an inpatient record Will not contain reportable final/confirmed diagnoses Typically contains Admission symptoms and co-existing conditions, as well as Admission diagnoses, which may or may not be one of the final diagnoses for the inpatient admission Discharge/final diagnoses must be submitted for the inpatient admission—not the H&P alone—and must be based on Inpatient ICD-9 coding guidelines

CMS Operations (Data Submission) H&P (cont’d) Physician visit within an inpatient stay If physician submits a separate claim based on evaluation of the patient as reflected on the H&P H&P (face-to-face encounter) is viewed as a physician visit  Reportable diagnoses documented in the H&P Could be used for risk adjustment; Could be used for risk adjustment; however, Must be submitted in accordance with outpatient ICD-9 coding guidelines 

CMS Operations (Data Submission) H&P (cont’d) Conclusions Risk adjustment is based on the final/confirmed diagnoses Submit risk adjustment diagnosis clusters based on the H&P only when there is an independent physician claim associated with the diagnosis Upon RA validation, MA organization submits H&P as stand-alone physician documentation; outpatient guidelines will be applied to determine if there is a confirmed diagnosis

CMS Operations (Data Submission) Lab and Pathology Reports Official Guidelines for Coding and Reporting (Section III, B. Abnormal Findings) “Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance.” Coders should not arbitrarily assign a final ICD-9 code based solely on the an abnormal finding Written interpretation of a tissue biopsy is not equivalent to the attending physician's medical diagnosis based on the patient's complete clinical picture

CMS Operations (Data Submission) Submitting risk adjustment diagnoses based on pathology Outpatient pathology facilities are unacceptable risk adjustment provider sources Physician pathology (i.e., specialty code 22) is acceptable for risk adjustment (when submitting diagnoses based on physician specialty code 22, refer to the guidance as stated on the prior slide)

CMS Operations (Data Submission) Diagnostic radiology data submission clarification Do not submit risk adjustment diagnoses based on any diagnostic radiology services Diagnostic radiologists typically do not document confirmed diagnoses Diagnosis confirmation comes from referring physicians or physician extenders Confirmed diagnoses are typically not assigned when reviewing medical record documentation from diagnostic radiology services alone This issue exists regardless of the type of diagnostic radiology bill (outpatient department, or physician component)

TECHNICAL ASSISTANCE UPDATES

TECHNICAL ASSISTANCE UPDATES 2008 Monthly Technical Assistance Sessions Enrollment & Payment Session March 26th Risk Adjustment Session April 30th Register today at www.tarsc.info

TECHNICAL ASSISTANCE UPDATES Next User Group Session April 16, 2008 Sessions will continue to be held on Wednesdays at 1:30 pm Eastern Standard Time

TECHNICAL ASSISTANCE UPDATES REGIONAL TECHNICAL ASSISTANCE SESSIONS Registration opens by March 31, 2008

TECHNICAL ASSISTANCE UPDATES *For detailed information and to register online log on to www.tarsc.info Technical Assistance Registration Service Center

QUESTIONS & ANSWERS

CLOSING

RESOURCES Sean Creighton (Director, Division Risk Adjustment Operations) sean.creighton@cms.hhs.gov Henry Thomas (Training, Project Officer) henry.thomas@cms.hhs.gov Lateefah Hughes (Data Validation, Team Lead) lateefah.hughes@cms.hhs.gov Louis Johnson (FERAS, Risk Adjustment Coordination) louis.johnson@cms.hhs.gov Chanda McNeal (Payment Issues) raf_payment_questions@cms.hhs.gov LTC www.tarsc.info CSSC www.csscoperations.com