Say a Medicare Advantage (MA) participant is diagnosed with heart failure. More than a decade ago, all MA programs (of which PACE is one) would submit this diagnosis to the Centers for Medicare & Medicaid Services (CMS) using the Risk Adjustment Processing System (RAPS). CMS then used data from RAPS to calculate risk scores. Risk scores, in turn, drive the risk-adjusted capitated payment to provide Medicare A, B services for that participant.
PACE is the only program that currently uses RAPS for the purpose of calculating risk scores. All other MAs moved to Encounter Data Submission for risk score calculation. Earlier this year, CMS provided guidance encouraging PACE organizations to start submitting risk adjustment data using the Encounter Data System (EDS).
The transition from RAPS to EDS significantly changes how PACE submits the appropriate data for risk adjustment calculation. Given the myriad of questions that arise as a result of this transition, here are answers to 4 key questions surrounding the move to EDS.
1. What will remain the same?
PACE programs will continue to document and code the same way, through ICD-10 diagnoses. However, risk adjustment submissions will now include substantially more data points. But perhaps the most important include HCPCS (Healthcare Common Procedure Coding System) and CPT (Current Procedural Terminology) codes. These codes give CMS insight into how a participant’s diagnoses are affecting the care given to treat those conditions, thereby providing more visibility into cost of care.
2. Will the transition impact program risk scores or reimbursement?
What CMS has measured to date indicates that when PACE programs move from RAPS to EDS, there should be very little impact to their risk score calculation, and therefore, their capitation and reconciliation payments. However, payments will be impacted as PACE moves to a newer version of the HCC (Hierarchical Condition Category) model.
That said, it is not yet clear what version of the HCC model will be used in risk score calculations for PACE. Currently, PACE uses CMS-HCC model version 22 (V22). Other MA plans have already moved to version 24 (V24). This version includes diagnoses that have a very high prevalence in PACE that aren’t part of the patient’s risk score in V22, such as dementia, which may positively influence the risk score. In addition to HCCs for dementia, V24 has HCCs for personality disorders and chronic kidney disease stage 3, among other diagnoses. With these additions, PACE programs could potentially see an increase in revenue.
However, the other MA plans are in a 2-year transition to version 28 (V28). This version does not include certain HCCs common to PACE, like those for vascular disease, malnutrition and thrombophilia. Moving to this newer Risk Score model may have a negative tug on the frailty factor. So, as more details are released, the longer-term impact on PACE program risk scores and reimbursement will become clearer.
3. How will the transition from RAPS to EDS benefit PACE?
Utilization management is key for PACE, and the move to EDS will bring more transparency. Compared to RAPS files, EDS submissions contain significantly more data points. So, the transition will give PACE programs the opportunity to dig deeper into how they are spending their dollars and utilizing services to care for their participants to help inform revenue management. For example, some PACE programs might look to analyze insight on diagnoses, conditions and costs.
The abundance of data will also support third parties like Capstone Risk Adjustment Services, as client service liaisons will have more information at their fingertips when working with clients. For example, while RAPS files simply indicate provider type, EDS submissions can show which provider delivered what service and when. This information is not available with RAPS files.
4. What can PACE programs do to prepare?
A common misconception is the transition from RAPS to EDS will not require a lift from PACE programs. In fact, programs should be working with their EHR provider to make sure they have all the processes and tools to capture and submit encounter data correctly using unlinked Chart Review Records (CRRs) on the 837p format. As mentioned, PACE programs are already capturing diagnoses. They will now be responsible for adding accurate procedure codes. This info will be needed from a program’s EHR and submitted to CMS.
As far as training, it’s important for the PACE clinical team to be familiar with new diagnoses included in later versions of the HCC model. Personality disorders, for example, are prevalent in the U.S. and are added in V24. So, there are educational opportunities for PACE providers to ensure they are up to speed on how to capture all active conditions a participant has.
Additionally, it’s vital for PACE programs to stay tuned into CMS as the source of truth on the transition. Programs should keep abreast of CMS communications for updates, including any technical assistance user group calls on the transition, to remain informed.
Programs can also leverage an expert partner for support. For additional questions on preparing for the RAPS to EDS transition, please contact our team. Clients of Capstone coding services who are interested in support capturing procedure codes can reach out to their client service liaison.
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