1. Risk Adjustment User Group
March 2008

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

3. INTRODUCTION

4. 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

5. 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.

6. PAYMENT PROCESS

7. 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
Final will take place in the
August payment.

8. DATA VALIDATION

9. DATA VALIDATION UPDATES Calendar Year 2007 Calendar Year 2006

10. OPERATIONS UPDATES

11. 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.

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

13. 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

14. 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 

15. 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

16. 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

17. 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)

18. 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)

19. TECHNICAL ASSISTANCE
UPDATES

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

21. 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

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

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

24. QUESTIONS & ANSWERS

25. CLOSING

26. RESOURCES
Sean Creighton (Director, Division Risk Adjustment Operations)
Henry Thomas (Training, Project Officer)
Lateefah Hughes (Data Validation, Team Lead)
Louis Johnson (FERAS, Risk Adjustment Coordination)
Chanda McNeal (Payment Issues)
LTC
CSSC