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Compliance Note:
Are You Up To Date?


Modifications Will Impact Medicare Risk Adjustment


Changes are on the way. CMS recently announced several

modifications that significantly impact the Medicare Risk Adjustment Program, which we have listed below.

Stay In The Know

CMS announced a revision to the CMS-HCC model, that includes the removal of more than 2,200 diagnoses from the risk adjustment model.  The new model will be phased in over three years and be fully implemented by 2026.  In addition to the removal of diagnoses, the following changes are being made:

  • ICD-10 will be used instead of ICD-9 codes, calibrating the model using 2018 diagnoses and 2019 expenditures.

  • Several new ICD-10 codes will be risk-adjusted:

    • Asthma Codes (J4550-J4452):

      • Severe persistent asthma, uncomplicated - J4550

      • Severe persistent asthma with (acute) exacerbation- J4551

    • Benign Carcinoid Tumors: Unspecified and Specified

      • Benign carcinoid tumor of the unspecified site - D3A00

    • Eating Disorders:

      • Anorexia nervosa, unspecified - F5000

      • Bulimia nervosa - F502          

It is recommended that you review the new codes in detail, and based on clinical evidence, evaluate these conditions at point of care. If your patient has one of the listed chronic conditions, please ensure accurate and compliant documentation of the condition in the medical record. To assist your practice, we have now incorporated suspected conditions (based on historical data, pharmacy, lab results, etc.) as part of your suspect report that you receive monthly. It is available for download in the Provider Portal. 

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