Introduction

PrimeTime Health Plan is a Medicare Advantage Plan. PrimeTime Health Plan receives payment based on the Risk Adjustment score. The members are offered more comprehensive benefits than Traditional Medicare.

Things changed in 2003. Plans are now encouraged to insure complex and less healthy members through a change in payment methodology from CMS-the HCC System. Yearly, the reimbursement from CMS is based on predicted cost of care rather than demographics. Input from the previous year's diagnostic codes drives the subsequent years cost prediction. This is the HCC System-Hierarchical Condition Category.

This on-line training provides an overview of the Risk Adjustment Program and the importance of submission and documentation of Hierarchical Condition Categories (HCC's).

To capture the quality and care of service documentation for PrimeTime Health Plan members.

The program is designed to provide education for individuals who document service and care received by our members.

• Provide information regarding CMS Risk Adjustment methodology, hierarchical condition categories/HCC and disease interactions.
• Identify the physician's role in documenting chronic disease in an office visit note and coding of ICD-9 diagnostic codes on the HCFA 1500.
• Understand the importance of assigning the ICD-9 with appropriate specificity (4th and 5th digits).
• Classify and assign accurate ICD-9 etiology/manifestation conventions for combination codes such as diabetes, hypertension and chronic kidney disease.
• Correctly assign ICD-9 codes based on sample office visit progress notes.