Tools

• Review of Opioid Use during the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)

  • Last Updated: 9/4/2018
  • 213 KB
  Explanation of recommendations to review patient's opioid use during the Initial Preventive Physical Exam and/or Annual Wellness Visit

5 Star

• 5 Star Guidebook-2018 Version

  • Last Updated: 3/15/2018
  • 979 KB
  The 2018 5 Star Guidebook is intended to help physicians and medical groups improve their performance against a number of CMS measures that are used to improve and reward successful implementation of best practices in healthcare

CMS-HCC Model Tools

• 2016 CMS HCC w/ RAFS

  • Last Updated: 5/26/2016
  • 2,122 KB
  This document contains the 2016 CMS-HCC Mappings in ICD-10, along with the Risk Adjustment Factor (RAF) score for each HCC.

• Announcement of Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter

  • Last Updated: 4/7/2015
  • 1,856 KB
  CMS has released the final MA rates for Part C and Part D, along with information on changes to the Stars program. The 2016 payment (2015 dates of service) will be based on 100% of the 2014 CMS-HCC Model. Last year, there was a blend of the 2013 CMS-HCC and 2014 CMS-HCC models by 67 percent and 33 percent, respectively.

• Announcement of Calendar Year (CY) 2015 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter

  • Last Updated: 4/7/2014
  • 883 KB

  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.

• 2014 CMS Announcement of Part C and D Rates and Call Letter

  • Last Updated: 4/1/2013
  • 1,322 KB
  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.

• 2013 Final CMS-HCC Factors

  • Last Updated: 1/11/2013
  • 63 KB
  This file contains multiple tabs, which include all of the 2013 Payment Year HCC coefficients and factors.

• 2011 HCC List-Diagnosis Code Grouping

  • Last Updated: 4/20/2011
  • 403 KB
  This file contains the CMS-HCC diagnosis code groupings, with documentation and coding information for problematic diagnosis codes.

• 2012 Model Diagnoses

  • Last Updated: 4/8/2011
  • 578 KB
  This file contains the diagnosis mappings for the CMS-HCC, ESRD/PACE-HCC and RxHCC models for the 2012 payment year (2011 service year).

• CMS-HCC Model Diagnoses for 2011

  • Last Updated: 9/29/2010
  • 471 KB
  ICD-9-CM Codes, CMS-HCC and RxHCC models.

• Final 2014 CMS-HCC Diagnosis Codes and Groupings

  • 128 KB
  This file contains the diagnosis codes at their highest level of specificity for the 2014 CMS-HCC model. These codes were taken from the CMS-HCC SAS software at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk_adjustment.html.

• 2013 CMS-HCC Model Diagnoses

  • 116 KB
  This file contains the diagnosis mappings for the CMS-HCC Model for the 2013 payment year (2012 dates of service).

• 2016 Combined All Model ICD-10 Mappings

  • 2,143 KB
  This final FY 2016 file contains all diagnosis codes for all CMS Medicare Advantage Risk Adjustment models for dates of service from 10-1-2015 to 9-30-2016.

EHR Tools

• SAFER Guides for EHR Systems

  • Last Updated: 2/21/2014
  • Zip File
  • 8,385 KB
  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.

• EMR White Paper

  • Last Updated: 12/31/2009
  • 257 KB
  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.

ICD-9 Coding and Documentation Tools

• Pocket Documentation Tip Sheet

  • Last Updated: 12/15/2015
  • 167 KB
  You can duplex print and fold this tip sheet in three for providers to carry in their pockets. These general documentation tips will help with most common issues physicians face. UPDATED for ICD-10!

• ICD-9 Files

  • Last Updated: 10/26/2012
  • Zip File
  • 6,494 KB
  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.

• 2012 ICD-9-CM Code Changes

  • Last Updated: 7/25/2011
  • 47 KB

  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.

  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.

• Diabetes and Renal Failure Coding

  • Last Updated: 12/15/2008
  • 108 KB
  A one page handout that explains the appropriate documentation and coding of diabetes and Chronic Kidney Disease.

Interactive Tools

• Top 200 ICD-9 Codes Converted to ICD-10

  • Last Updated: 10/15/2015
  • 657 KB

  This document is an update to our Top 200 ICD-9 codes section of the Interactive Guidebook. We’ve crosswalked the current top 200 ICD-9 codes to ICD-10, and provided documentation advice (including reference to a better code when possible) for the 200 most popular diagnoses submitted in 2015 under the ICD-9 coding structure. We hope this will assist you in making the transition to ICD-10 coding easier.

  Because most of the advice in the current Interactive Guidebook is still useful, and applies to the CMS-HCC model itself, we have no plans to update the Guidebook at this time. However, we will provide updates to important information that no longer applies, so that you can stay current in your knowledge of the CMS-HCC model, and coding in general.

• Interactive Guide Book

  • Last Updated: 2/28/2012
  • 6 KB
  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.

• Risk Score Calculator

  • Last Updated: 2/28/2012
  • 6 KB
  The calculator includes 2008-2018 payment year factors

Medicare tools

• Medicare Learning Network (MLN) Guided Pathways Provider Specific Medicare Resources

  • Last Updated: 9/1/2016
  • 2,921 KB
  The curriculum is designed as a pathway for Physician and Other Health Care Professionals to find Medicare resources, such as official Medicare manuals, including those related to Medicare Advantage.

Miscellaneous Tools

• Documentation of Atherosclerosis of the Aorta

  • Last Updated: 1/5/2016
  • 91 KB
  This one page handout describes challenges physicians face when documenting atherosclerosis of the aorta, and how to avoid them. A must for any physician who sees patients with this diagnosis. (ICD-10)

• PHQ9 Form

  • Last Updated: 8/17/2015
  • 70 KB
  This PHQ9 form can be used to assess patients for potential depressive disorders as a part of your 5 Star and other patient assessments.

• CMS User Group Documents

  • Last Updated: 2/3/2015
  • Zip File
  • 1,672 KB
  This is a collection of old CMS RAPS User Group documents that are no longer on the CSSCOperations websites. They contain Questions and Answers from CMS Staff regarding risk adjustment, and coding.

• Risk Adjustment Submission Timetable

  • Last Updated: 1/21/2015
  • 14 KB
  This tool shows the timeline for submission of risk adjustment data through dates of service 6/30/2015. Note that beginning 1/1/2012, Full Encounter Data submission is required.

• CMS Announcement for new HCPCS codes to replace modifier -59. Effective January 1, 2015

  • Last Updated: 12/31/2014
  • 93 KB
  Effective: January 1. 2015 there are four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” Please make sure your billing staffs are aware of the coding modifier changes.

• HHS and DOJ letter on medical record cloning

  • Last Updated: 10/9/2012
  • 112 KB
  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.

• Acute CVA Fact Sheet

  • Last Updated: 12/8/2011
  • 20 KB
  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:

• Sepsis Fact Sheet

  • Last Updated: 12/8/2011
  • 19 KB
  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:

• Unstable Angina/Acute Coronary Syndrome Fact Sheet

  • Last Updated: 12/8/2011
  • 22 KB
  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:

• Acute MI Fact Sheet

  • Last Updated: 12/8/2011
  • 20 KB
  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:

• Acute Respiratory Failure Fact Sheet

  • Last Updated: 12/8/2011
  • 56 KB
  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:

• Physician Signature Requirements

  • Last Updated: 8/18/2011
  • Zip File
  • 234 KB

  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: 8/19/2008
  • 5,188 KB
  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.

• Acute CVA Fact Sheet

  • 40 KB
  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. NOW UPDATED FOR ICD-10.

• Acute MI Fact Sheet

  • 40 KB
  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. NOW UPDATED FOR ICD-10.

• Acute MI Fact Sheet

  • 61 KB
  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. NOW UPDATED FOR ICD-10.

• Sepsis Fact Sheet

  • 40 KB
  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. NOW UPDATED FOR ICD-10.

• Unstable Angina/Acute Coronary Syndrome Fact Sheet

  • 44 KB
  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. NOW UPDATED FOR ICD-10.

RADV Tools

• CMS Pilot RADV Findings

  • 87 KB
  CMS Pilot RADV Findings—for services rendered July 1, 2001 through June 30, 2002, Published July 27, 2004.

• CMS RADV Checklist

  • 33 KB
  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.

• CMS RADV Questions and Answers

  • 64 KB
  CMS answers to past questions related to Risk Adjustment Data Validation Studies.

Risk Adjustment Data Validation (RADV) Tools and Documents

• Final RADV Extrapolation Methodology Released

  • Last Updated: 2/28/2012
  • 110 KB
  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.

• • Last Updated: 4/25/2011
  • 87 KB
  CMS Pilot RADV Findings—for services rendered July 1, 2001 through June 30, 2002, Published July 27, 2004.

• • Last Updated: 4/25/2011
  • 64 KB
  CMS answers to past questions related to Risk Adjustment Data Validation Studies.

• Risk Adjustment Data Validation Resources

  • Last Updated: 4/25/2011
  • 64 KB
  CMS answers to past questions related to Risk Adjustment Data Validation Studies.

• • Last Updated: 4/25/2011
  • 33 KB
  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.

Risk Adjustment Processing System (RAPS)-Tools

• 2016 acceptable physician specialties for RAPS

  • Last Updated: 3/26/2015
  • 41 KB
  For 2015 dates of service, CMS has added specialty C3—Interventional Cardiology. No other changes have been made.

• CMS Approved Specialties for Risk Adjustment--Updated for 2014

  • Last Updated: 11/25/2014
  • 101 KB

• These two files are excerpts from CMS publications/presentations that describe the use by health plans of the A,B and C Health Risk Assessment flags we will be using in our RAPS transmissions to CMS.

  • 122 KB

Risk Adjustment Processing Tools

• ABC Health Risk adjustment flags

  • 122 KB
  This file is an excerpt from CMS presentatio that describe the use by health plans of the A,B and C Health Risk Assessment flags we will be using in our RAPS transmissions to CMS.

• Additional ABC Health Risk Adjustment Flag information

  • 130 KB
  This file is an excerpt from CMS publication (software release _ that describes she use by health plans of the A,B and C Health Risk Assessment flags we will be using in our RAPS transmissions to CMS.