2021-05-06 Risk Adjustment Use Case Meeting

FHIR Risk Adjustment PSS 

• FHIR Management Group (FMG) approved the PSS on 4/21
• Currently under eVote by the Clinical Steering Division

eVote- underway, which ends on 5/14/21. Next will go to the TSC for approval.

Continue discussing Risk Adjustment Report data elements requirements from Payer to Provider and operation requirements

• Patient demographics and diagnosis codes are most important on the HCC codes. Other elements may confuse the HCC model. example- HCC codes may be in different places on different versions. 
  • proposed to have the risk adjustment model and version be optional 
  • hard to not have it optional- as payers cannot determine the diagnosis without the provider
• allow model to be exchange between payers and providers so that when each are looking at it, there is no ambiguity

Condition code- Include HCC ID, Name, status, status date and diagnosis code

Last DOS- removed- as the data is derivable from supporting resources

Condition type- examples of chronic, acute, persistent- previously called disease type.

• problem- can have more than one type, persistent and chronic, persistent and acute
• payers may mark some disease states for care gaps. may vary from payer to payers
  • may want to flag it if acute type that is latent- but is based on clinical judgement
• this information is subjective and based on payer discretion- easy to define acute, but not persistent
• at this time- will take out from phase 1 currently.

Date of onset and date of diagnosis- will this be included? Not at this time because the information is typically taken form the problem list but most payers may not be looking at problem list

• If placing it as optional- would payers be using it different ways? If we are clear on what it entails then it may work out.