Announcement of Calendar Year (CY) 2015 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter Last updated on 4/7/2014
CMS has posted the combined 2015 Announcement of Methodological Changes for Calendar Year (CY) 2015 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2015 Call Letter. The following keychanges to the Advance Notice were made:
2015 payment year we will blend the risk scores calculated using the 2013 CMS-HCC and 2014 CMS-HCC models by 67 percent and 33 percent, respectively.
CMS is not implementing, for 2015, the proposed policy to exclude, for payment purposes, diagnoses identified during a home visit that are not confirmed by a subsequent clinical encounter.
CMS will use both Full Encounter Data and RAPS data to calculate 2015 payment. CMS will notify us when Full Encounter Data alone will be used
There are a number of other important changes, and we recommend you review the notice fully. Download Now [884 KB] >
Interactive Guide Book Last updated on 2/28/2012
A user friendly, interactive version of Accuracy in Documentation and Coding, our most requested provider risk adjustment (RA) tool. Includes 2013 payment year HCC Factors.
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Risk Score Calculator Last updated on 2/28/2012
Quarterly EHUG Recordings
This tool allows you to calculate a member’s actual risk score from the CMS-HCC Model. The calculator includes 2008 – 2013 payment year factors.
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EHUG Slides and Audio Recording Last Updated 3/21/2014
ICD-9 Coding and Documentation Tools
We will be posting future EHUG materials in this space.
ICD-9 Files Last Updated 10/26/2012
Full text of the ICD-9 codes, by year. NOTE: Due to the October 1, 2014 implementation of ICD-10, no new ICD-9 diagnosis codes were added for 2013. The 2012 version of ICD-9 is still in effect.
NEW: Full text of the 2012 ICD-9.
Primary Care Superbill Last updated on 1/14/2013
This Primary Care Superbill has been updated to incorporate important 5 Star CPT II codes.
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Physician Pocket Coding Cards Last updated on 5/9/2011
A pocket sized ICD-9 tool for PCPs and hospitalists. Just print on card stock front and back, fold in thirds and it’s ready to use.
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Superbill Generator Last updated on 3/17/2011
The Superbill Generator allows you to select ICD-9 codes based on specialty or body system, and create a diagnosis code based superbill.
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Diabetes and Renal Failure Coding Last updated on 12/15 2008
A one page handout that explains the appropriate documentation and coding of diabetes and Chronic Kidney Disease.
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2012 ICD-9-CM Code Changes Last updated on 7/25/2011
Risk Adjustment Processing System (RAPS)-Tools
CMS-HCC Model Tools
This is the final full update of ICD-9 codes prior to the implementation of ICD-10 on October 1, 2013. The codes in this file are effective 10-1-2011. The ICD-9 update on 10-1-2012 will only reflect new diseases and/or technologies. There are 168 new ICD-9 diagnosis codes, 41 diagnosis codes with title (description) changes, and 33 invalid codes. There are no deleted codes for 2012. There are three tabs in the file.
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We do not expect to have an update to the CMS-HCC Model until sometime after October 1, 2011. Any revisions to the CMS-HCC Model will be effective 1-1-2012.
2014 CMS Announcement of Part C and D Rates and Call Letter Last updated on 4/1/2013
On 4-1-2013, CMS published the attached final notice of Part C & D Rates for 2014. In addition to a new CMS-HCC Model, CMS has announced the implementation of collection of information related to Health Risk Assessments in 2014, and Coding Intensity Adjustment for 2014 payment.
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2013 Final CMS-HCC Factors Last updated on 1/11/2013
Risk Adjustment Data Validation (RADV) Tools and Documents
This file contains multiple tabs, which include all of the 2013 Payment Year HCC coefficients and factors.
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Final RADV Extrapolation Methodology Released Last updated on 2/28/2012
CMS has released the final overpayment extrapolation methodology for Risk Adjustment Data Validation Audits. Based on the notice, there are three major changes: 1) Audits start in 2011 2) The inclusion of a FFS adjuster and 3) Submission of multiple medical records, not just one best medical record. We are awaiting further information on this information, which CMS anticipates releasing at the time of the first RADV audits under the extrapolation methodology.
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Risk Adjustment Data Validation Resources Last updated 4/25/2011
CMS answers to past questions related to Risk Adjustment Data Validation Studies.
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This checklist was used in the last National RADV to assist health plans in selecting the "One Best Medical Record" for submission. For more information on the RADV process, please review the RAPS Participant Guide on this page.
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CMS Pilot RADV Findings—for services rendered July 1, 2001 through June 30, 2002, Published July 27, 2004.
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Safer Guides for EHR Systems Last updated on 2/21/2014
These guides and checklists will help you evaluate the Safety and Security of you EHR system. Prepared by the The Office of the National Coordinator for Health Information Technology (ONC), and found on HealthIT.gov website, these are just a few of the many tools available to you on the site.
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EMR White Paper Last updated on 12/31/2009
This paper provides up-to-date basic facts about the importance of EMRs and their practical utility for busy clinicians and professionals. If you do not have time to read a whole book on this topic, download this file now.
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Annual Wellness Visit and Health Risk Assessment Forms Last updated on 1/11/2013
SCAN has developed an Annual Wellness Visit progress note form to be used with the ICE approved Health Risk Assessment (HRA) form. These forms will assist you in capturing all of the required elements of the Annual Wellness Visit (AWV). You should complete the last two pages of the AWV form for the patient to take away as their personalized prevention plan service form. The HRA form must be completed by the patient prior to the visit. You should retain a copy of these pages in your record.
In addition to the AWV and HRA forms, we have prepared instructions to help you complete these forms. You can download these forms here
You can review a presentation to help you with completing an Annual Wellness Visit by clicking here
CMS Approved Specialties for Risk Adjustment Last updated on 5/31/2012
Effective 1-1-2012, CMS has added three new approved physician specialties: Sleep Medicine; Cardiac Electrophysiology and Sports Medicine. The full list is available here.
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HHS and DOJ letter on medical record cloning Last updated on 10/9/2012
This cautionary letter was sent to five American health care associations. It notes that there are indications that cloning of medical records is occurring, and some providers seem to be using this to game the system.
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Life threatening conditions fact sheets Last updated on 12/8/2011
These fact sheets provide important documentation information for physicians and other clinicians about commonly mis-coded conditions in an office setting. All of them are brief, and designed to help clinicians—most can be printed on a half sheet of printer paper! We hope you’ll use them to educate your clinicians about appropriate documentation in an office setting. Choose from:
Risk Adjustment Submission Timetable Last updated on 11/12/2012
This CMS tool shows the timeline for submission of risk adjustment data through dates of service 12/31/13. Note that beginning 1/1/2012, Full Encounter Data submission is required.
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Summary of CY2009 Rate Announcement Last updated on 4/30/2008
This analysis of the Medicare Advantage 2009 Rate Announcement describes changes to CMS payment for 2009, an explanation of the proposed coding intensity adjustment, and CMS risk adjustment data validation (RADV) plans for 2008 and beyond.
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Risk Model Factor Comparison Last updated on 4/30/2008
A supplement to the Summary of the CY2009 Rate Announcement, this tool compares payment year 2008 and 2009 HCC and demographic factors.
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Risk Score Calculator - 2007 Last updated on 1/1/2008
Downloadable version of the 2007 (DOS) risk score calculator. The 2008/2009 version is available online.
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Physician Signature Requirements Last updated on 8/18/2011
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Looking for information on Signature logs? In the attached file, we’ve provided a number of resources for you on physician signature requirements. Although CMS will not accept a signature log for a Risk Adjustment Data Validation (RADV) for MA members, they are still acceptable in Fee-For-Service (FFS) Medicare.
If you would like to use a signature log for FFS Medicare and other insurers who accept them, we have provided a signature log for your use. Remember that the signature you use on the log must be your normal signature, so that a match between the log and a medical record is possible.
In the file you will find:
- A brief presentation on Medicare signature requirements
- A sample signature log
- A Medicare Medlearn Article on physician signature requirements. NOTE: These requirements do not apply to Medicare Advantage
CMS Risk Adjustment Processing System (RAPS) Participant Guide Last updated on 8/19/2008
This is the official Health Plan training manual for Part C. Contents include everything from the history of Risk Adjustment, Data Submission, and Medical Record Review.
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Partial Code Freeze Prior to ICD-10 Implementation Last updated on 10/20/2010
On September 15, 2010, the ICD-9-CM Coordination and Maintenance Committee finalized a decision to implement a partial freeze for both ICD-9-CM codes and ICD-10-CM and ICD-10-PCS codes before the ICD-10 implementation date of October 1, 2013. This CMS document explains what’s known to date.
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