A change by CMS to its claims submission process for Medicare Advantage affects both physicians and their practices. Here's what you need to know.
If it seems that the world of coding and claims submission is always changing, the perception isn’t far off the mark. CMS may soon be replacing its current Risk Adjustment Payment System (RAPS) process for Medicare Advantage risk adjustment with the Encounter Data Processing System (EDPS). The transition not only affects Medicare Advantage Organizations (MAO), but the physicians who contract with them. Here is a brief overview of what this means for providers.
The current methodology for setting county base rates (calibrating the model) for Medicare Advantage plans is based on cost (claims) data collected from fee-for-service providers. That will change when CMS transitions to EDPS and begins to set rates on the fee-for-service equivalent pricing using the "encounter data" submitted by Medicare Advantage plans. Although CMS has been collecting Medicare Advantage encounter data for the last two years, it has not set the official date to begin calibrating rates using this formula. Additionally, diagnoses used for calculation of CMS' hierarchical condition category (HCC) or "risk adjustment factor" may come from Medicare Advantage encounter data and not from RAPs as it is today.
What is the Difference between RAPS and EDPS?
EDPS data is much more detailed than RAPS data sets. While RAPS data is edited for enrollment, duplicates, and validity of diagnosis codes, EDPS not only includes these but also requires CPT codes while looking for coverage and clinical consistencies. EDPS data must pass National Correct Coding Initiative (CCI) edits similar to those used with fee-for-service claims. The volume and complexity of the additional information required creates more chance for errors and thus rejections of submitted diagnosis codes. That can have cash flow repercussions farther down the line for MAOs and providers.
Although a transition date has yet to be set, we do know RAPS will continue to run parallel to the EDPS in 2014. That is why it is important for health plans to continue to submit data in both the RAPS and EDPS format throughout 2014.
Here are some preparatory steps that physician practices can take within their billing and coding operation to help ensure the transition to EDPS is a smooth one:
• Ensure data accuracy. By instituting a system of checks and balances in documentation, you can help ensure all services are documented correctly. This will require an in-depth knowledge of fee-for-service billing protocols as well as complete diagnoses with CPT coding and documentation.
• Track rejections. Most practice management systems have functionality that allows billers to generate reports on claims rejections on an ongoing basis. Tracking and trending rejections will allow practices to see where the data submission problems are occurring and correct them well ahead of full EDPS implementation. Be sure to track rejections by reason codes so data errors can be resolved and resubmitted quickly in order to recover dollars that may otherwise be lost.
• Conduct regular audits. Billing supervisors should review a sampling of charts quarterly to determine if the documentation protocols for correct coding are being applied appropriately.
CMS issues regular updates on data submission requirements and tools for complying with them. Your office can stay up to date on the latest encounter data news by subscribing to updates from the CSSC Operations website and the Technical Assistance Registration Service Center website. CMS also regularly publishes its Encounter Data Newsletter with news and updates.