Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: October 31, 2014

Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server

Question: Can issuers use health assessments as a source of risk adjustment diagnosis codes?

Answer: Diagnosis codes from health assessments may be submitted in accordance with the medical claim submission process (if a claim for a paid service or accepted encounter was not previously submitted and accepted) or may be submitted in accordance with the supplemental diagnosis code submission process (if a claim was previously submitted and accepted on the EDGE server). An issuer may use a Diagnosis Code derived from a health assessment if all of the following apply: The Diagnosis Code is supported by medical record documentation and complies with standard coding principles and guidelines. The Diagnosis Code is related to medical services performed during the patient visit and is the result of a medical service(s) that resulted in a paid medical claim or reported encounter. The Diagnosis Code is the result of medical services performed by a State licensed medical provider. The Diagnosis Code complies with general medical claim file or supplemental diagnosis file submission business rules. For additional information, please review the EDGE Server Business Rules (ESBR) section 8, located under the Distributed Data Collection (DDC) program area at https://www.REGTAP.info in the REGTAP Library.

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