Risk Adjustment (RA) FAQ
Guidance for FAQ regarding Risk Adjustment Operations and Risk Scores
Program Area: Risk Adjustment (RA)
Question: During Risk Adjustment (RA) claims selection, must a claim include both an acceptable Current Procedural Terminology (CPT) code and an acceptable bill type, or will the External Data Gathering Environment (EDGE) server accept a claim that has either an acceptable CPT code or an acceptable bill type?
Answer: The EDGE server will automatically consider institutional inpatient claims with bill types: 111 and 117. For institutional outpatient bill types: 131, 137, 711, 717, 761, 767, 771, 777, 851 and 857 and all professional claims to be included in RA claims selection, at least one (1) CPT code that is acceptable for RA must be on the claim. For more information, see the RA New Issuer Series: Risk Score Calculation Part 1 document, located under the RA program area at https://www.REGTAP.info in the REGTAP Library. For additional information please refer to the RA Risk Scores Part One (1) Computer-based Training (CBT) (12/31/18), located under the RA program area at https://www.regtap.info/reg_librarye.php?i=2141&type=v in the REGTAP Library.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 22, 2019
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