Resource Guide 2003 p1 - 10 27 03-RevB - CSSC Operations

2003 Regional Risk Adjustment Training For Medicare+Choice Organizations

RESOURCE GUIDE

RESOURCE GUIDE

About this Guide

This Resource Guide is intended to help Medicare+Choice organizations, providers, physicians, and third party submitters locate information specific to risk adjustment.

The purpose of this Resource Guide is to identify and supply resources that will simplify and clarify both the terminology and the processes employed in the submission of risk adjustment data. An emphasis is given to recent, policy-relevant material.

This Resource Guide is a helpful tool for those who need a quick reference for technical concepts, or for those who need to provide employees with an introductory presentation to the risk adjustment data process. Where possible and appropriate, "screen shots" of important resources on the Internet have been included. These pages may also be utilized as a suitable visual aid for risk adjustment data instructors to enhance their presentation.

The information listed in the Resource Guide is arranged in seven sections: ? RISK ADJUSTMENT ACRONYMS AND TERMS ? CODING RESOURCES ? CMS WEB RESOURCES ? CMS REFERENCE DOCUMENTS ? CSSC WEB RESOURCES ? CSSC REFERENCE DOCUMENTS ? RISK ADJUSTMENT PROCESSING SYSTEM CROSSWALKS ? MEDICARE BENEFICIARY DATABASE USER'S MANUAL AND APPLICATION FOR ACCESS

GENERAL CONTACT INFORMATION

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) -

CMS Contacts for Technical Issues Jeff Grant: jgrant1@cms. Bobbie Knickman: bknickman@cms. Jan Keys: jkeys@cms. Cynthia Tudor: ctudor@cms. Henry Thomas: hthomas@cms.

CUSTOMER SERVICE AND SUPPORT CENTER (CSSC) ? The CSSC website provides "one-stop shopping" for M+C organizations regarding risk adjustment data submission needs. Visit to register for email updates from the CSSC. The updates will serve as notification that new or updated information has been added to the website.

CSSC Contact Information 877-534-2772 (toll-free) mcoservice@

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2003 Regional Risk Adjustment Training For Medicare+Choice Organizations RESOURCE GUIDE

ASPEN SYSTEMS CORPORATION For general questions about training and Risk Adjustment User Groups, please email Aspen Systems Corporation at the encounterdata@.

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2003 Regional Risk Adjustment Training For Medicare+Choice Organizations

RESOURCE GUIDE

TABLE OF CONTENTS RISK ADJUSTMENT ACRONYMS AND TERMS ..............................................................1 CODING RESOURCES ..................................................................................................4

V and E Codes .............................................................................................................5 B Neoplasm Guidelines ......................................................................................................9

CMS WEB RESOURCES ..............................................................................................10 CMS REFERENCE DOCUMENTS..................................................................................12

Accessing HPMS..............................................................................................13 Instructions for Risk Adjustment Implementation.........................................14 CSSC WEB RESOURCES .............................................................................................25 CSSC REFERENCE DOCUMENTS.................................................................................34

CSSC EDI Letter ............................................................................................................35 CMS EDI Agreement .....................................................................................................37 Risk Adjustment Data Submitter Application...............................................................40 NDM ? RAPS Application...............................................................................................41

RISK ADJUSTMENT PROCESSING SYSTEM CROSSWALKS ........................................44 TRAINING RESOURCES .............................................................................................50

How to Calculate Demographic and CMS-HCC Risk Adjusted Payments .....................51 Risk Adjustment and the CMS-HCC Model ? Attachments A, B, and C.........................53 Using the Reduced Set of ICD-9-CM Codes in the CMS-HCC Model .............................55 FINAL ICD-9 Codes and HCCs.................................................................................. 57 B Diagnosis Cluster Benchmarks .............................................................................. 136 B Risk Adjustment Output Report Available for 2004 ? Letter ................................ 138 B Model Output Beneficiary RAF File Layout ............................................................ 140 B Risk Adjustment Model Output Report ? Example ................................................ 155 B Coding Workshop ? Index for Fracture Example .................................................. 156 B

MEDICARE BENEFICIARY DATABASE USER'S MANUAL AND APPLICATION FOR ACCESS.................................................................................158 B

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2003 Regional Risk Adjustment Training For Medicare+Choice Organizations RESOURCE GUIDE

RISK ADJUSTMENT ACRONYMS AND TERMS

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2003 Regional Risk Adjustment Training For Medicare+Choice Organizations

RESOURCE GUIDE

RISK ADJUSTMENT ACRONYMS AND TERMS

ACRONYM

ADS AGNS AMA ANSI ANSI X12 837 ASC ASPEN BBA BBRA BIPA CHF CMHC CMS CMS-HCC CPT CSSC CWF DCP DDE DHHS DOB DoD DOS DRG DX EDI FERAS FFS FQHC FTP GHP H# HCC HCFA 1500 HEDIS HIC# HIPAA HMO HPMS ICD-9-CM ICN IP JCAHO MBD M+C Organization MDCN MMCS MMR

TERM

Alternative Data Sources AT&T Global Network Services American Medical Association American National Standards Institute Variable Length File Format for Electronic Submission of Encounter Data Ambulatory Surgical Center Aspen Systems Corporation Balanced Budget Act of 1997 Balanced Budget Refinement Act 1999 Benefits Improvement and Protection Act of 2000 Congestive Heart Failure Community Mental Health Center Centers for Medicare & Medicaid Services CMS Refined Hierarchical Condition Category Risk Adjustment Model Current Procedural Terminology Customer Service and Support Center Common Working File Data Collection Period Direct Data Entry Department of Health & Human Services Date of Birth Department of Defense Dates of Service Diagnosis Related Group Diagnosis Electronic Data Interchange Front-End Risk Adjustment System Fee for Service Federally Qualified Health Center File Transfer Protocol Group Health Plan Payment System M+C Organization CMS Contract Number Hierarchical Condition Category Medicare Part B Claim Filing Form Health Plan Employer Data Information Set Health Insurance Claim Number (Beneficiary Medicare ID#) Health Insurance Portability and Accountability Act Health Maintenance Organization Health Plan Management System International Classification of Diseases, Ninth Revision, Clinical Modification Internal Claim Number Internet Protocol Joint Commission on Accreditation of Health Care Organizations Medicare Beneficiary Database Medicare+Choice Organization Medicare Data Communications Network Medicare Managed Care System Monthly Membership Report

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