HCC University

Time 2020-10-21 04:02:30

Web Name: HCC University

WebSite: http://hccublog.scanhealthplan.com

ID:89001

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SCAN is committed to partnering with our physician providers in offering high quality geriatric care to our members. A significant part of that effort is to assist our providers in the provision of accurate coding that will contribute to the quality of care and support the expected revenue from the Medicare program. To this end, we present the following tools and education for all the physicians and groups providing care to our members.Recently, we've noticed that there are a number of Skilled Nursing Facility claims/encounters rejected by CMS due to the following reasons:Skilled Nursing Facility Claims required Health Insurance Prospective Payment System (HIPPS) codes not present on the claim.HIPPS Codes and Revenue Codes conflictHospital to Skilled Nursing Facility within 24 hours.All of these issues can be remedied, by following the Centers for Medicare and Medicaid Services guidelines for billing of Skilled Nursing Facility guidance, including the correct use of HIPPS codes.Although CMS allows Medicare Advantage plans to provide services which may not meet the coverage criteria in Fee-for-service (FFS) Medicare, provision of services and submission of an encounter data are two distinct things. So, while coverage may be extended in some cases when FFS guidelines are not met, encounter data must meet FFS billing requirements in order to be processed. And CMS does require that all services must be submitted as encounter data, whether or not CMS covers them.In order to ensure your encounter data is processed correctly, you should follow the instructions contained in the CMS Skilled Nursing Facility (SNF) Billing Reference. For complete instructions on HIPPS Codes, you should review the HIPPS code page on the CMS website as well.Finally, in order to ensure that your claim/encounter for a SNF transfer within 24 hours, be sure to use Condition Code 40 on the encounter.The importance of correct encounter data cannot be stressed enough. In order for CMS to have an accurate and complete picture of the services provided to our members, encounters must be processed to completion. By and large, that means they must meet the requirements of FFS medicare when they are sent to health plans. This ensures that they will be correctly processed, and that CMS can more accurately assess the care provided to MA members.If you have questions regarding CMS Encounter Data, contact Michelle Nguyen of our Encounter Data team atMNguyen3@scanhealthplan.com.As you know, CMS now uses a combination of RAPS (Risk AdjustmentProcessing System) data and encounter data submitted thru EDPS (Encounter DataProcessing System) as inputs into the payment system for projecting RAFs (RiskAdjustment Factors), which is a key input to payment model for MAPD (MedicareAdvantage Prescription Drug) health plans. CMS requires that allencounter data be submitted by MAPD health plans, including services notcovered by CMS in Fee-For-Service (FFS) Medicare.Due to the growth of payment strategies such as capitationin MAPD, providers are no longer financially incentivized to provide completedata as they were in the traditional claims billing process. This hasbeen a widely identified trend in MAPD professional data, but also occurs inthe inpatient setting which often contains more robust information then otherplaces of service. Missing encounter data and the growth of the gap inthese data (between MAPD and FFS) has a number of important ramifications forMAPD:It causes inaccuracies in payment because treated conditions are notreported and therefore not loaded into the payment model It suggests a distorted picture of members true disease burden as beinglower than the actual It suggests incorrectly to CMS that MAPD members are receiving fewerservices than beneficiaries in traditional Medicare (FFS)The purposeful filtering of encounter data submitted to the plan withthe goal of providing only incremental HCC model data Downstream data that medical groups processes as claims are not always extractedand reported. This is especially true when the groups encounter data andclaims data are on different platforms. Selective reporting from providers of only risk adjustable diagnoses inMAPD and only providing a single E M procedure code so that the encounterwill process Submitting reporting from providers of only diagnoses linked to aprocedure code for traditional Medicare claims or only the minimum needed forthe claim to processWhile there are no mechanisms in traditional Medicare atpresent to submit additional diagnosis data (maximums are currently =8diagnoses for professional, =25 diagnoses for institutional), it simportant to submit all documented diagnoses and procedures for both programs.In traditional Medicare where there are more diagnoses then 8, we would suggestthat the provider or biller first choose linked diagnoses followed by thediagnoses that most accurately reflect the need for the visit and evaluationsconducted at that service. Similarly, reporting all CPT/HCPCS codesisimportant since it is the only way that CMS can gain an accurate picture ofprocedures performed with the goal of trying to understand and compare valuebetween the programs. At present we believe that there are a number of systematicbiases that are impacting the accuracy of the view CMS has on the health statusof the entire Medicare population, biasing towards fewer CPT/HCPCS for MAPD andfewer ICD codes for traditional FFS.NOTE:Remember, SCAN s Encounter and Risk Adjustment provider teamis here to assist you. Please reach out to Michelle Nguyen at MNguyen3@scanhealthplan.com forassistance.Good afternoon, all. Today, we're lucky to have a special guest post, by one of SCAN's Coding Quality Specialists, Megha Patel, CCS, CPC. Megha has done a lot of hard work for us, compiling all the significant changes to the Official Guidelines for Coding and Reporting, beginning with the switch from ICD-9-CM to ICD-10-CM:ICD -9 to ICD-10Official Coding Guideline Updates1.10/01/2015: ICD-9 to ICD-10 updated October 1, 2015. with Angina: Use combination codes for CAD with Angina, A causal relationshipcan be assumed in a patient with both Atherosclerosis and angina pectoris. Itis not necessary to code Angina Pectoris separately. Sequelaeof CVA: Weakness due to previous CVA should be coded as Hemiplegia/Hemiparesis.Sequelaeof CVA: Hemiplegia/Hemiparesis/Monoplegia identify whether the dominant or non-dominantside of affected. If provider didn tdocumented dominant or non-dominant, the default is to assume the right side isthe dominant side. If left side affected, the default is non-dominant. with Hyperglycemia: Uncontrolled DM, Inadequately Controlled, Out ofcontrolled, Poorly Controlled should be coded as Hyperglycemia. DiabetesKetoacidosis: ICD-10 CM does not provide a specific code for Type II diabeticKetoacidosis. Assign code E13.10 Other Specified Diabetes with Ketoacidosis asper Coding Clinic First Quarter of 2013.2.03/18/2016: with Complications Assumed relationship. The guidelines published in the firstquarter 2016 issue of AHA Coding Clinic on pg. 11. According to thisclarification, the subterm with in the index should be interrupted as a linkbetween diabetes and any of those conditions indented under the word with . ** Thelinkage between diabetes and Osteomyelitis used to be assumed in ICD-9 but itis not assumed in ICD -10 (10/01/2015-10/01/2016 Not coded). There is noassumed relationship till October 1, 2016.3.10/01/2016: UncontrolledDM: Uncontrolled DM is classified by type and whether it is hyperglycemia orhypoglycemia. There is no default code for uncontrolled DM . Effective Oct. 1,2016, uncontrolled diabetes can be referenced as Hyperglycemia or Hypoglycemia.Hypertension with CHF: Presumes a causalrelationship between hypertension and heart involvement. with Asthma: COPD with asthma only coded as J44.9. If type of asthma notdocumented J45.909 should not be coded. Unspecified is not type of asthma. 4.10/01/2017: DiabeticKetoacidosis: October 1, 2017 updated with new codes for Diabetes Ketoacidosis(Type II). E11.10 Type II DM with Ketoacidosis w/o Coma and E11.11 Type II DMwith Ketoacidosis w/ Coma. COPD,Emphysema and Chronic Bronchitis all documented: Assign J449 only, becauseJ43.9 Emphysema has Exclude 1 note (Emphysema with chronic bronchitis). J44.9has Include note Chronic Bronchitis with emphysema. (J439 is Emphysema withoutChronic Bronchitis) (J449 is Emphysema with Chronic Bronchitis). with Emphysema: J43.9 Emphysema assigned as Emphysema is specific type of COPD.with an Acute Exacerbation of COPD: Assign J43.9. Both codes have Exclude 1note to each other. J439 is without Chronic Bronchitis and J449 is with ChronicBronchitis. Emphysema is type of COPD so Acute Exacerbation of COPD is coversin J43.9. Thanks, Megha--for doing all the heavy lifting!Remember, you can always download the full text of the ICD-10-CM guidelines on our website, athttp://hccuniversity.com/asset/154d663f-95bf-4a59-a1fd-a6e4eb7c8477The January CMS Encounter Data Sweep deadlinehas been extended! This is the FINAL CMS sweep impacting 2016 DOS (2017 payment) andrequires the submission of encounters for DOS range01/01/2016 à12/31/2016. CMS currently plans a 75% RAPS and Fee forService and 25% EDS and Fee for Service blended risk score based on 2016 DOS. Additionally, TODAYis the CMS Final Deadline Date for the March CMS Encounter Data Sweep, which requiresthe submission of encounters for DOS range 01/01/2017 à12/31/2017. CMS currently plans a 85%RAPS and Fee for Service and 15% EDS and Fee for Service blended risk scorebased on 2017 DOS.SCAN has one date for you to manage towardsfor the January 2018 sweep (2016 DOS):Ø SCAN Deadline for ProviderPartners: EOB Friday, April 27, 2018 RAPS onlyo After this deadline,SCAN will NOT process any RAPSfiles received for the January CMS sweep*Note: 2016 DOS EDSdeadline has been extended to September 2018SCAN has two dates for you to manage towardsfor the March 2018 sweep:Ø SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018 closed o This target dateensures that SCAN has adequate time to complete processing prior to the healthplan cut-off date by CMSØ SCAN Deadline for ProviderPartners: EOB Friday, February 23, 2018 closedoAfterthis deadline, SCAN will NOT process any files received for theMarch CMS sweep7 STEPS YOU CAN TAKE TO PREPARE:Review your SCAN monthly Encounter Submission Reports March reports were uploaded to the SCAN Encounter Data Portal on 3/2/2018. The next ESRs will be uploaded the first week of April 2018.This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab - HCCs and Encounters.This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab - HCCs and Encounters.ANSWER: A report containing all diagnosis codesreceived from your group for dates of service 01/01/2016 - 12/31/2016 and01/01/2017 - 12/31/2017.This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab - HCCs and Encounters. ANSWER: A report containinga list of all the PCNs received from your group for dates of service 01/01/2016- 12/31/2016 and 01/01/2017 - 12/31/2017.The PCN field providesyou with the ID received from you for each encounter (a.k.a. claim ID). You mayreconcile the list of PCNs against your system to ensure that SCAN has receivedall of your PCNs. If any are missing on our list that exist in your system,then you can identify those as needing to be submitted to SCAN immediatelyIf you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.*The above reports are designed to helpyou ensure that all possible encounter data for SCAN members has been sent toSCAN to meet the CMS health plan cut-off date of May 4, 2018 for the JanuarySweep (RAPS only) and March 2, 2018 for the March Sweep.AdditionalSteps:Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.Send these files sooner than later; please do not to wait until April 27, 2018 to upload your 2016 DOS files for the January Sweep (RAPS only). Additionally, please do not wait until February 23, 2018 to upload your 2017 DOS files for the March Sweep.ICE files should only be used to submit additional DX codes or deletes of DX codes. SCAN expects toreceive all original encounter data records via your normal clearinghouseworkflow.Follow up on additional cleanup requests (contact your respective HCI representative with your direct questions) Provider Name Mismatch (PNM) rejection reportsRendering Provider/Entity (RPX) rejection reportsEDS Full Encounter Data rejection reportsInvalid DX rejection reportsICE File Pend reportsLast day to submit all 01/01/2016 - 12/31/2016 DOS encounters for RAPS to your Clearinghouse: 04/27/2018Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2016 - 12/31/2016 to SCAN: 04/27/2018January CMS Sweep RAPS deadline for SCAN: 05/04/2018Submit all 01/01/2017 - 12/31/2017 DOS encounters to your Clearinghouse: 02/23/2018Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2017 - 12/31/2017 to SCAN: 02/23/2018March CMS Sweep deadline for SCAN: 03/02/2018* Remember: SCAN has two dates for providerpartners to manage towards for the January and March Sweep:Ø January Sweep SCAN Target Date for ProviderPartners: EOB Friday, December29, 2017- closedo This target date ensuresthat SCAN has adequate time to complete processing prior to the health plancut-off date by CMSØ January Sweep SCAN Deadline (RAPS only) for ProviderPartners: EOB Friday, April 27, 2018o After this deadline,SCAN will NOT process any files received for the January CMSsweepØ March Sweep SCAN Target Date for ProviderPartners: EOB Friday, January26, 2018- closedo This target dateensures that SCAN has adequate time to complete processing prior to the healthplan cut-off date by CMSØ March Sweep SCAN Deadline for ProviderPartners: EOB Friday, February 23, 2018- closedo After this deadline,SCAN will NOT process any files received for the March CMS sweepPlease be prepared for continuedcommunication from SCAN. We look forward to supporting and working with youduring this upcoming sweep period!If you have any questions or concerns, pleasefeel free to contact me directly or reach out to SCAN s HCI Representative:o Michelle Nguyen: MNguyen3@scanhealthplan.comBest regards,Christina CabiltesSupervisor, HCIProjectsThe January CMS Encounter Data Sweep iscoming to a close. TODAY is the Final Deadline Date to submit the remainder ofyour 2016 DOS Encounter Data! This is the FINAL CMS sweepimpacting 2016 DOS (2017 payment) and requires the submission of encounters forDOS range 01/01/2016 à12/31/2016.CMS currently plans a 75% RAPS and Fee for Service and 25% EDS and Fee forService blended risk score based on 2016 DOS. Additionally, we are now 4 weeks away from SCAN s Final Deadline Datefor the March CMS Encounter Data Sweep, which requires the submission ofencounters for DOS range 01/01/2017 à12/31/2017.CMS currently plans a 85% RAPS and Fee for Service and 15% EDS and Fee forService blended risk score based on 2017 DOS.SCAN has two dates for you to manage towardsfor the January 2018 sweep:Ø SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017 - closedo This target dateensures that SCAN has adequate time to complete processing prior to the healthplan cut-off date by CMSØ SCAN Deadline for ProviderPartners: EOB Friday, January 26, 2018o After this deadline,SCAN will NOT process any files received for the January CMSsweepSCAN has two dates for you to manage towardsfor the March 2018 sweep:Ø SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018o This target dateensures that SCAN has adequate time to complete processing prior to the healthplan cut-off date by CMSØ SCAN Deadline for ProviderPartners: EOB Friday, February 23, 2018o After this deadline,SCAN will NOT process any files received for the March CMS sweep7 STEPS YOU CAN TAKE TO PREPARE:Review your SCAN monthly Encounter Submission Reports January reports were uploaded to the SCAN Encounter Data Portal on 1/5/2018. The next ESRs will be uploaded the first week of February 2018.This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab - HCCs and Encounters.This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab - HCCs and Encounters.ANSWER: A report containing all diagnosis codesreceived from your group for dates of service 01/01/2016 - 12/31/2016 and01/01/2017 - 12/31/2017.This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab - HCCs and Encounters. ANSWER: A report containinga list of all the PCNs received from your group for dates of service 01/01/2016- 12/31/2016 and 01/01/2017 - 12/31/2017.The PCN field providesyou with the ID received from you for each encounter (a.k.a. claim ID). You mayreconcile the list of PCNs against your system to ensure that SCAN has receivedall of your PCNs. If any are missing on our list that exist in your system,then you can identify those as needing to be submitted to SCAN immediatelyIf you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.*The above reports are designed to helpyou ensure that all possible encounter data for SCAN members has been sent toSCAN to meet the CMS health plan cut-off date of January 31, 2018 for theJanuary Sweep and March 2, 2018 for the March Sweep.AdditionalSteps:Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.Send these files sooner than later; please do not to wait until January 26, 2017 to upload your 2016 DOS files for the January Sweep. Additionally, please do not wait until February 23, 2018 to upload your 2017 DOS files for the March Sweep.ICE files should only be used to submit additional DX codes or deletes of DX codes. SCAN expects toreceive all original encounter data records via your normal clearinghouseworkflow.Follow up on additional cleanup requests (contact your respective HCI representative with your direct questions) Provider Name Mismatch (PNM) rejection reportsRendering Provider/Entity (RPX) rejection reportsEDS Full Encounter Data rejection reportsInvalid DX rejection reportsICE File Pend reportsLast day to submit all 01/01/2016 - 12/31/2016 DOS encounters to your Clearinghouse: 01/26/2018Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2016 - 12/31/2016 to SCAN: 01/26/2018January CMS Sweep deadline for SCAN: 01/31/2018Submit all 01/01/2017 - 12/31/2017 DOS encounters to your Clearinghouse: 02/23/2018Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2017 - 12/31/2017 to SCAN: 02/23/2018March CMS Sweep deadline for SCAN: 03/02/2018* Remember: SCAN has two dates for providerpartners to manage towards for the January and March Sweep:Ø January Sweep SCAN Target Date for ProviderPartners: EOB Friday, December29, 2017- closedo This target dateensures that SCAN has adequate time to complete processing prior to the healthplan cut-off date by CMSØ January Sweep SCAN Deadline for ProviderPartners: EOB Friday, January 26, 2018o After this deadline,SCAN will NOT process any files received for the January CMSsweepØ March Sweep SCAN Target Date for ProviderPartners: EOB Friday, January26, 2018o This target dateensures that SCAN has adequate time to complete processing prior to the healthplan cut-off date by CMSØ March Sweep SCAN Deadline for ProviderPartners: EOB Friday, February 23, 2018o After this deadline,SCAN will NOT process any files received for the March CMS sweepPlease be prepared for continuedcommunication from SCAN. We look forward to supporting and working with youduring this upcoming sweep period!If you have any questions or concerns, pleasefeel free to contact me directly or reach out to SCAN s HCI Representative:o Michelle Nguyen: MNguyen3@scanhealthplan.comBest regards,Christina CabiltesSupervisor, HCIProjectsWe get a lot of questions in our Ask A Coder inbox, coding@scanhealthplan.com . There is no doubt that far and away, the most ...New Documents Posted to the HCCUniversity.comWe have posted a number of new documents to the Full Encounter Data/ICD 10 page of HCCUniversity.com. Scroll down to CMS Encounter Work-Gr...New CMS Full Encounter Data Document Posted to HCCUniversity.comThere is a new document related to the CMS Full Encounter Data workgroups that are ongoing. It has been posted on SCAN Health Plan : Full En...Special Guest Posting by Coding Quality Specialist, Megha Patel, CCS, CPC- Official Coding Guideline ChangesGood afternoon, all. Today, we re lucky to have a special guest post, by one of SCAN s Coding Quality Specialists, Megha Patel, CCS...Free Continuing Medical Education for Physicians from CMS Attention Physicians: CMS is providing free Continuing Medical Education through the completion of online training modules. All modu...Annual Wellness Visits in Medicare Advantage and Fee-for-serviceWe continue to receive questions from Medical Groups about the Annual Wellness Visit (AWV). As we ve noted previously, CMS limits the A...Use of this site is subject to SCAN Health Plan s Terms of Use. Review our Legal DisclaimersAll comments to HCC University blog postings are reviewed for their appropriateness prior to posting. Comments are subject to the following rules, and are posted at the sole discretion of the moderator. These rules are subject to change at any time at the moderator s sole discretion. Comments Specifically not Posted: Comments related to: the competitive business activities of companies or participants; profits, premiums, prices, surcharges, or discounts; endorsement of suppliers; refusal to deal with suppliers; market behavior of any Health Plan; any other topic involving potentially anticompetitive practice; topics related to specifics on incentives or performance bonuses for RA activities; those specifically recommending a RA Solution (i.e., software used for risk adjustment); any other comment that does not advance the discussion of the current topic or is otherwise deemed inappropriate by the moderator.Comments which may be Posted All topics of discussion must be based on factual information, for example: Coding rules or guidelines, changes to the model (proposed and finalized),inclusion or exclusion of diagnosis codes in the CMS-HCC or Rx-HCC model, discussion of the annual Advance notice, discussion of the annual Announcement provisions, CMS posted rules related to coding or Risk Adjustment, general questions about medical records, mentions of a specific solution that are integral to the comment (e.g., we use blank report from Ascender to determine _______) which do not constitute an endorsement of the product; Recommendations of other CMS or other tools which are available at no charge to the public (e.g, the American Academy of Family Practice has a good general physical exam template. It can be downloaded at:_______).

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