User Guide — Patient Risk Adjustment and the Patient Risk Dashboard

athenahealth has developed functionality within athenaOne to help organizations document and bill appropriately for chronic conditions tied to risk adjustment.

In athenaClinicals, the Patient Risk dashboard displays gaps in documentation for high-volume, high impact chronic conditions, such as diabetes, during the point-of-care workflow. In just a few clicks, a provider can move a potential diagnosis surfaced in the Patient Risk dashboard into the Assessment & Plan (A/P) section of the encounter. athenahealth pulls diagnosis gaps from third party external sources, athenahealth claims, and claims added manually by coders.

In athenaOne, reports are available in the Report Library to provide real-time, actionable insight into how your organization is performing related to several metrics that athenahealth has developed specifically for risk adjustment. For more details, see Reporting on diagnosis gaps.

Both the features in athenaClinicals and the reports available in the Report Library run on a calendar-year basis because most risk contracts reset at the beginning of the calendar year.

As the industry moves toward a value-based healthcare system, an increasing portion of your revenue will be tied to how effectively your organization can control costs for complex patients. However, you're compensated properly only if payers know how complex your patients are.

There are a few reasons why organizations aren't always compensated properly:

• Diagnoses are not documented to the highest level of specificity

• Comorbidities of the primary disease (which impact risk scores) are not captured

• Risk scores reset annually and chronic conditions are not consistently recaptured on claims

It takes buy-in from an entire organization to ensure that diagnoses are documented properly for risk adjustment:

• Billing providers or clinical staff should review the Patient Risk Adjustment (HCC/RAF): Diagnosis Gaps Report before patients come in so that they have a sense of the patients' chronic conditions and where any gaps may exist in documentation or care.

• Billing providers should review the Patient Risk dashboard as part of pre-visit planning and/or during an exam to ensure that patients' chronic conditions are addressed and documented appropriately.

• Practice managers and leaders should review the Patient Risk Adjustment reports to assess how well providers and departments are documenting diagnoses and using the patient risk adjustment features in athenaClinicals.

• Coding staff should use the Patient Risk dashboard to add suggested diagnoses based on chart review when clinically appropriate, if this is part of their workflow.

The following diagram illustrates the diagnosis gaps workflow in athenaOne where:

• Potential diagnosis is the condition manually added by HCC coders or billing staff during risk adjustment chart prep/reviews. In addition, any prior patient diagnosis condition based on claims documented in athenaOne in the last three calendar years, but not addressed in the current calendar year by the provider, are classified as potential diagnosis gaps that need to be addressed by providers.

• Dismissed diagnosis is one that the provider dismissed because it is not clinically relevant to the patient.

• Completed diagnosis (risk adjustment factor) is a diagnosis state when the diagnosis is addressed in an encounter and a claim is generated in the current calendar year. Any completed diagnosis in the previous year resurfaces as a potential diagnosis for re-diagnosis at the start of the new calendar year (Jan 1st).

External diagnosis gaps associated with the CMS-HCC risk adjustment model, along with athenahealth's source (manually added and athenahealth claims), contribute to the patient risk adjustment score. This aggregated data view on the Patient Risk dashboard allows providers better insight of patients' risk conditions and allows them to take appropriate action at the point of care. For more details on the sources of diagnosis gaps, see Understanding the data in the Patient Risk dashboard.

Potential diagnoses

Potential (or clinically verified) diagnoses have previously appeared on a claim for a patient and are eligible for recapture in the current calendar year.

Potential diagnosis gaps:

• Have associated ICD-10 codes that have previously appeared on a claim for a patient

• Are identified natively from athenahealth claims

• Can be manually added

• Are surfaced from third-party integrations via API (for more details, see Understanding the data in the Patient Risk dashboard)

Billing staff and others can manually add potential diagnoses to the Patient Risk dashboard, based on gaps that they find on claims, by clicking the plus icon next to Potential Diagnoses.

Note: Providers can manually add only CMS-HCC potential diagnosis gaps.

The potential diagnosis appears on the Patient Risk dashboard and the patient's gap risk score increases to accommodate the new potential diagnosis. During this patient's next visit, the provider can view the potential diagnosis on the Patient Risk dashboard and, if applicable, add it to the Assessment & Plan section of the encounter.

Each potential diagnosis includes the source (for example, MANUAL or CLAIM), which identifies the information that supports the suggestion (for example, details on a historical claim or a note from the billing staff).

See the following step-by-step instructions for addressing potential diagnoses in the Patient Risk dashboard:

• To add a potential diagnosis to the Patient Risk dashboard
• To accept a potential or suspected diagnosis during an encounter
• To update an ICD-10 code

Suspected diagnoses

Suspected (or clinically inferred) diagnoses are inferred from clinical evidence. The clinical evidence surfaces with the suspected diagnosis gap in the Patient Risk dashboard. We support suspected diagnosis gaps from external sources only.

A suspected (or clinically inferred) diagnosis is one that is likely to be present for a patient but is not supported by a documented condition in the patient’s chart or on a claim. This should not be confused with a previously dismissed condition. Supporting clinical facts are provided to help you decide if you should dismiss a diagnosis, clean up the patient chart, or document an HCC-related problem or diagnosis for the patient.

Suspected diagnoses may be based on the following: Medications, Procedures, Measurements and Results, Previous Diagnoses, and Notes.

Suspected diagnoses are based on the condition category. The provider must determine the ICD-10 code. In addition, the Patient Risk dashboard displays only suspected diagnosis gaps from third-party external sources received via API.

For step-by-step instructions on addressing suspected diagnoses in the Patient Risk dashboard, see To accept a potential or suspected diagnosis during an encounter.

The Patient Risk dashboard displays the potential and suspected diagnosis gaps added into the patient's record from payers. Provider feedback is sent to payers on the day following any action taken on external diagnosis gaps received from payers.

Note: Payer diagnosis gaps appear if your organization uses both athenaClinicals and athenaCollector. They also appear if you use athenaClinicals only and are enrolled in HEDIS or MIPS quality programs or have payer data enabled. If you want to opt-out of payer data appearing in athenaClinicals, contact the CSC.

• You'll notice that the data from the partners includes the ICD-10 code (for potential diagnoses only) and the relevant source information.

• Additional supporting details related to the external diagnosis gaps, such as provider or hospital names and payer names, are also shown when received by payers. The name of the health insurance plan appears as the source of the gap, in lieu of the payer name, when that information is provided by the payer.

• The risk score displayed in the dashboard is adjusted to include the external CMS-HCC diagnosis gaps received. These diagnosis gaps are actionable and providers can dismiss, reinstate a dismissed diagnosis, or choose a diagnosis during the encounter workflow.

Patient diagnosis gaps received are reconciled against the gaps in the patient's chart from other sources (manual/past year claims). This ensures duplicate codes only appear once.

For more details on the reconciliation and display logic, see How diagnosis gaps are reconciled and displayed.

If a potential or suspected diagnosis is not clinically relevant to the patient, the provider can dismiss the diagnosis to remove it from the Potential Diagnoses or Suspected Diagnoses section. Dismissed diagnosis gaps appear in the Dismissed Diagnoses section of the Patient Risk dashboard.

Providers can select a reason for dismissal or enter a justification when dismissing the gap:

For example, if a patient no longer has a skin cancer that was diagnosed and treated in the previous year, the provider can select "condition resolved" as the reason for dismissal.

Providers are encouraged to use this feature to dismiss diagnoses that are no longer clinically relevant. athenahealth monitors the dismissal rates across the network and adjusts the diagnoses that surface in the Patient Risk dashboard based on how often providers dismiss diagnoses.

For step-by-step instructions, see To dismiss a diagnosis.

Note: Diagnosis gaps are dismissed at the ICD-10 code level. This means that if a provider dismisses an ICD-10 code, all instances of the same ICD-10 code received from various sources are also considered dismissed in the Patient Risk dashboard. If an ICD-10 code is captured from a claim, and a provider has previously dismissed that same ICD-10 code, the Patient Risk dashboard displays the diagnosis as dismissed.

If you dismiss a diagnosis from the Patient Risk dashboard in error, or the diagnosis is later found to be relevant for the patient, you can reinstate the diagnosis and return it to the list as an open gap. For step-by-step directions, see To reinstate a dismissed diagnosis.

For details on the retention period for dismissed gaps, see Retention period for dismissed diagnosis gaps.

For details on the system behavior in various scenarios for dismissing and reinstating diagnosis gaps, see Dismissing and reinstating diagnosis gaps.

In the Risk Adjustment Factor section in the Patient Risk dashboard, providers can view the patient's CMS-HCC risk score:

Note: The blended risk score is calculated only for CMS-HCC diagnosis gaps and is not calculated for gaps from other risk models.

The risk score includes all of the diagnoses that have been addressed and closed in the current calendar year. The risk score calculation includes demographic, HCC, interaction, and condition count variables.

For more details on how this score is calculated, see Risk adjustment factors and blended scoring.

Note: You can display the patient risk score instead of the potential diagnosis count in the patient's problem list. For step-by-step directions, see To show patient risk score instead of potential diagnoses in the Problems list.

Tip: Administrators can set this preference at the practice level so the same preference is applied to all users. See To update practice-wide user preferences.

1. Display the User Preferences page: On the Main Menu, click Settings > User Preferences.
2. Select the Show patient risk score instead of potential diagnosis count in Problem List option.
   
3. Click Submit.

Billing staff and others can manually add potential diagnoses to the Patient Risk dashboard. Manually added potential diagnoses appear with the source MANUAL and identify the information that supports the suggestion (for example, a note from the billing staff).

1. In the patient chart, click the Problems tab on the left side of the page. The Patient Risk score or x Diagnosis Gaps appears at the top of the list. Click this link to view the Patient Risk dashboard.
   
   
2. Click the plus icon next to Potential Diagnoses. The diagnosis selector opens.
   
   
3. Search for the potential diagnosis and select the most appropriate diagnosis. Each diagnosis includes an associated RAF weight.
4. Reason — Add a reason for the suggestion and then click Add.
   
   
   The potential diagnosis appears on the Patient Risk dashboard.

During this patient's next visit, the provider can view the potential diagnosis on the Patient Risk dashboard and, if applicable, add it to the Assessment & Plan section.

During an encounter, from the Patient Risk dashboard, you can accept a potential or suspected diagnosis and add it directly to the Assessment & Plan section of the encounter.

1. In the patient chart, click the Problems tab on the left side of the page. The Patient Risk score or x Diagnosis Gaps appears at the top of the list. Click this link to view the Patient Risk dashboard.
   
   
   The Patient Risk dashboard displays potential diagnoses and suspected diagnoses.
   
   Note: If a potential diagnosis includes an obsolete ICD-10 code, click Replace ICD to replace the obsolete code with the updated reportable code (athenaOne provides an alternative code, but you can select a different code). When you click Replace ICD, the ICD-10 code search window opens. From this window, you can search for the ICD-10 code you need to replace and select from the list of specific codes.

2. If the ICD-10 code is still relevant and accurate for the patient, click Choose Diagnosis to select a diagnosis from the diagnosis search window.
   
3. Start typing an ICD-10 code or SNOMED diagnosis that belongs to the same HCC to display a list of relevant SNOMED diagnoses. If you search for an ICD-10 code that is not relevant to the HCC, the field does not display any matching results. Select the appropriate diagnosis.
   
   
   Note: For best results, type the ICD-10 code in the search field without any additional text.

4. For suspected diagnoses, you must add an ICD-10 code in addition to selecting a SNOMED diagnosis. After you select a diagnosis from the diagnosis search window, click Select ICD. From the ICD-10 code search window, select the appropriate ICD-10 code.
   

5. If you select an ICD-10 code that requires a manifestation, click SPECIFY MANIFESTATION and make a selection from the list.
   
   Note: Buddy codes are secondary billing codes that are required for certain ICD-10 codes to fully justify the associated HCC. The Patient Risk dashboard supports rules and workflows to ensure proper documentation of buddy codes.
6. Click Add to A/P to add the diagnosis and billing code to the Assessment & Plan section of the encounter.
   
   
   The diagnosis is added to the Assessment & Plan section. The count on the Patient Risk section of the Problems tab decreases by 1, and the current risk score adjusts accordingly.
   
   Note: The addressed gap does not appear as closed in the Risk Adjustment Factor section of the dashboard until the diagnosis is seen on a claim. In addition, only CMS-HCC diagnosis gaps show as closed. For non-CMS-HCC gaps, if you select an ICD-10 code and that code is seen on a claim, the condition category is marked as appearing on the claim ("APPEAREDONCLAIM" status) and the non-CMS-HCC gap no longer appears in the Patient Risk dashboard.

If a potential or suspected diagnosis is not clinically relevant to the patient, you can dismiss the diagnosis to remove it from the Patient Risk dashboard.

1. In the patient chart, click the Problems tab on the left side of the page. The Patient Risk score or x Diagnosis Gaps appears at the top of the list. Click this link to view the Patient Risk dashboard.

2. Hover over the diagnosis and click the Delete icon that appears.
   The Reason for Dismissal field appears.
   

   • To record a reason for dismissing this diagnosis, select one of the reasons displayed. If none of the reasons apply, enter the reason in the Other field (up to 470 characters) and click Save.

   • If you do not want to record a reason for dismissing the diagnosis, click Save

   If you entered a reason, the reason appears below the dismissed diagnosis in the Dismissed Diagnoses section.

3. To view the list of dismissed diagnoses, expand the Dismissed Diagnosis section in the Patient Risk dashboard. Each dismissed diagnosis displays the dismissal justification and the user who dismissed the diagnosis.
   

Note: Diagnosis gaps are dismissed at the ICD-10 code level. This means that if a provider dismisses an ICD-10 code, all instances of the same ICD-10 code received from various sources are also considered dismissed in the Patient Risk dashboard. If an ICD-10 code is captured from a claim, and a provider has previously dismissed that same ICD-10 code, the Patient Risk dashboard displays the diagnosis as dismissed. If you remove a diagnosis from the patient chart by mistake, you can reinstate it (see To reinstate a dismissed diagnosis).

If you dismiss a diagnosis from the Patient Risk dashboard in error, or the diagnosis is later found to be relevant for the patient, you can return the diagnosis to the list.

1. In the patient chart, click the Problems tab on the left side of the page. The Patient Risk score or x Diagnosis Gaps appears at the top of the list. Click this link to view the Patient Risk dashboard.
   
   The number of dismissed diagnoses appears next to the Dismissed Diagnoses section in the dashboard.
   
   
2. Expand the Dismissed Diagnoses section and click the reactivate icon next to the dismissed diagnosis that you want to reactivate.
   
   The diagnosis reappears in the list.

Follow this procedure during an encounter to update an existing ICD-10 code in the Patient Risk dashboard.

1. In the patient chart, click the Problems tab on the left side of the page. The Patient Risk score or x Diagnosis Gaps appears at the top of the list. Click this link to view the Patient Risk dashboard.
   
   The Patient Risk dashboard shows potential diagnoses that appeared in a claim last year, but have not been coded this year.
   
   Note: If a potential diagnosis includes an obsolete ICD-10 code, click Replace ICD to replace the obsolete code with the updated reportable code (athenaOne provides an alternative code, but you can select a different code). When you click Replace ICD, the ICD-10 code search window opens. From this window, you can search for the ICD-10 code you need to replace and select from the list of specific codes.
2. Choose a diagnosis for the ICD-10 code you want to update. On the Patient Risk dashboard, click Choose Diagnosis to open the diagnosis search window.

3. Start typing an ICD-10 code that belongs to the same HCC to display a list of relevant SNOMED diagnoses. If you search for an ICD-10 code that is not relevant to the HCC, the field does not display any matching results. Select the appropriate code.
   
   Note: For best results, type the ICD-10 code in the search field without any additional text.

4. After you choose a diagnosis, the Update ICD option appears. Click Update ICD to change the current ICD-10 code to another code.

   

5. In the ICD-10 code search window, select the appropriate ICD-10 code:

   
   The new code now appears in the Patient Risk dashboard.

Providers can see suspected patient risk diagnosis gaps sourced by athenahealth partners, such as payers, in the Problems tab.

A suspected diagnosis is one that is likely to be present for a patient but is not supported by a previously documented condition on a claim. Supporting clinical facts are provided to help you decide if you should dismiss a diagnosis, clean up the patient chart, or document an HCC-related problem or diagnosis for the patient.

Suspected diagnoses may be based on the following:  Medications, Procedures, Measurements and Results, Previous Diagnoses, and Notes.

For more information on the difference between potential and suspected diagnoses, see Potential and suspected diagnoses.

The diagnosis gaps functionality in athenaClinicals sources gaps both natively and externally.

Manual

Providers and billing staff can manually add potential CMS-HCC diagnosis gaps to the Patient Risk dashboard. Through the diagnosis selector, users can search for and select the most appropriate ICD-10 code to record the diagnosis gap in the dashboard.

Claims

Previous claims within athenaOne are scrubbed and CMS-HCC eligible ICD-10 codes are used to create potential CMS-HCC diagnosis gaps.

athenahealth Population Health

Potential CMS-HCC diagnosis gaps that have been identified as open or closed from athenahealth Population Health are integrated into athenaClinicals.

Third parties

Payers share open potential and suspected diagnosis gaps for any risk adjustment model via the third party Risk Gaps API, and these gaps surface in athenaClinicals.

Payer integrations are enabled by default. If you want to opt-out of payer data appearing in athenaClinicals, contact the CSC. For a comprehensive list of payer partners, see Overview: Moment of Care Connections (MoCC) Participating payers for care gaps and diagnosis gaps.

In addition, customers can share open potential and suspected diagnosis gaps for any risk adjustment model via the third party Risk Gaps API.

The Risk Gaps third-party API facilitates publishing patients' diagnosis gaps periodically from external partners and customers. Ingested diagnosis gaps are reconciled and deduplicated before the gaps surface in the risk adjustment workflow.

Risk adjustment workflows can support other risk adjustment models beyond the CMS-HCC model, including CDPS and HHS-HCC. Payers and other third parties can surface potential and suspected diagnosis gaps from any risk model in the Patient Risk dashboard via the Risk Gaps API.

For more details on the API integrations, see Risk Adjustment on the Developer Portal.

If your organization would like to receive and manage diagnosis gaps from additional risk models, contact the CSC: On the Main Menu, click Support then Create Case or Call.

If your organization uses athenaClinicals and athenahealth Population Health, data from both products can be used in athenaClinicals to provide more accurate and timely information about a patient's potential diagnoses and risk adjustment factor.

athenahealth Population Health uses three years of historical post-adjudicated claims data provided by payers, including claims from outside the network.

The additional information from athenahealth Population Health can improve the diagnosis and treatment of chronic conditions, reduce manual coordination between ACO administrators and providers, and increase revenue for payment models that are calibrated to the RAF score of the at-risk population.

Because the post-adjudicated claims data from athenahealth Population Health is included, the Patient Risk dashboard in athenaClinicals shows you a more complete accounting of the following:

• Potential and suspected diagnoses
• Risk adjustment factors
• Risk scores

For more details, see the following Population Health resources:

• Service Overview — Population Health
• Risk Adjustment
• Person Center — Problems Tab

CMS-HCC risk adjustment model

athenaClinicals has full support of the CMS-HCC risk adjustment model through an HCC engine. Each year, athenahealth updates this engine with CMS-HCC specifications.

Full support of the CMS-HCC model means that athenaClinicals can:

• Natively identify CMS-HCC diagnosis gaps from all claims for all patients

• Allow users to manually add potential CMS-HCC diagnosis gaps in the Patient Risk dashboard

• Surface a risk score for closed CMS-HCC diagnosis gaps

• Close CMS-HCC diagnosis gaps based on the ICD-10 codes billed on an eligible claim for an HCC category

For details on the latest HCC to ICD-10 mappings from CMS, see the Risk Adjustment resource from CMS.

Model agnostic approach

Practices that manage diagnosis gaps from risk adjustment models other than the CMS-HCC model, such as CDPS and HHS-HCC, can view and address these potential diagnosis gaps in the Patient Risk dashboard.

athenaClinicals has limited support for other risk models besides CMS-HCC. athenaClinicals can accept diagnosis gaps from non-CMS-HCC models via the Risk Gaps API and surface those gaps in the Patient Risk dashboard.

Limited support for non-CMS-HCC gaps means:

• athenaClinicals can ingest non-CMS-HCC diagnosis gaps received from payers and other third parties via the Risk Gaps API.

• athenaClinicals cannot calculate risk scores for non-CMS-HCC diagnosis gaps.

• Non-CMS-HCC diagnosis gaps are not marked as closed in the Patient Risk dashboard; instead, when an ICD-10 code for a non-CMS-HCC gap is seen on a claim, the condition category is marked as appearing on the claim ("APPEAREDONCLAIM" status) and the non-CMS-HCC gap no longer appears in the Patient Risk dashboard.

The Patient Risk dashboard currently supports two CMS-HCC model versions — version 24 (2020) and version 28 (2024) during the phased implementation period of the version 28 model, which began on January 1, 2023.

For details on the ICD-10 codes of v24 and v28 HCCs, see the following sections in the Updates to the Patient Risk Dashboard to Align with CMS's HCC v28 Updates release note:

• v24 ICD-10 codes supported in 2024

• ICD-10 codes newly added to HCCs in v28

• v24 ICD-10 codes retained in v28

See the following sections for more details on how the Patient Risk dashboard supports the v24 and v28 models during 2024.

Manually adding potential diagnosis gaps

 

Through 2024, you can search for and add ICD-10 codes of both the v24 and v28 model versions in the Patient Risk dashboard. ICD-10 codes that are part of the v24 model version and will be phased out in v28 are indicated by the suffix (v24) next to the HCC information:

 

Users can manually add ICD-10 codes that are part of the:

• v28 model version only — ICD-10 codes that are newly added to the HCC risk adjustment model.
• v24 and v28 model versions — ICD-10 codes that continue to be eligible for risk adjustment.

 

When you add an ICD-10 code that belongs to both the v24 and v28 model versions, only the HCC information of the v28 model version appears in the Patient Risk dashboard.

 

As an example, the ICD-10 code E10.8 (Type 1 diabetes mellitus with unspecified complications) is part of both the v24 and v28 model versions. Under the v24 model version, E10.8 was part of HCC 18. Under the v28 model version, E10.8 is part of HCC 38. As shown in the screenshot below, the Patient Risk dashboard displays only CMS-HCC 38 (v28) information for E10.8:

 

ICD-10 codes from athenahealth claims

 

Through 2024, the HCC engine identifies ICD-10 codes of both the v24 and v28 model versions from athenahealth claims and surfaces them in the Patient Risk dashboard.

 

HCCs of ICD-10 codes captured from a previous year claim (up to the past 3 years) appear as open potential diagnosis gaps in the Patient Risk dashboard, whereas ICD-10 codes captured from a current year claim are considered closed for the current year and appear in the Risk Adjustment Factors section of the Patient Risk dashboard.

 

Diagnosis gaps from external sources

 

In the Patient Risk dashboard, external sources indicate model version v24 or v28 for the diagnosis gap.

 

Potential diagnosis gaps

If the ICD-10 code is associated with a single HCC:

• in only v24, the system displays the v24 HCC.
  • For example, A0103 is linked to HCC 115 in v24 and is not linked to any HCC in v28. When A0103 is sent through the risk gaps API, the HCC information displayed is HCC 115 (v24).
• in only v28, the system displays the v28 HCC.
  • For example, D3A00 is not linked to any HCC in v24 and is linked to HCC 22 in v28. When D3A00 is sent through the risk gaps API, the HCC information displayed is HCC 22 (v28).
• in both v24 and v28, the system displays the v28 HCC.
  • For example, C100 is linked to HCC 11 in v24 and linked HCC 21 in v28. When C100 is sent through the risk gaps API, the HCC information displayed is HCC 21 (v28).

 

If the ICD-10 code is associated with more than one HCC:

• in only v24, the system displays the v24 HCC with the higher RAF weight.
  • For example, E093533 is linked to HCC 18 and HCC 122 in v24 and is not linked to any HCC in v28. When E093533 is sent through the risk gaps API, the HCC information displayed is HCC 18 (v24).
• in both v24 and v28, the system displays the v28 HCC with the higher RAF weight.
  • For example, Z943 is linked to HCC 186 in v24 and linked to HCC 221 and HCC 276 in v28. When Z943 is sent through the risk gaps API, the HCC information displayed is HCC 276.

 

Suspected diagnosis gaps

When a CMS-HCC suspected diagnosis gap with only an HCC ID is received without a model version, the HCC engine assumes the model version to be v28 by default and validates the HCC ID accordingly. If the HCC ID is a part of v28, the gap is accepted. If not, the gap is rejected.

 

For example, if a suspected diagnosis gap is sent with:

• HCC 2 and model version v24, the gap is accepted.
• HCC 36 and model version v24, the gap is rejected because HCC 36 does not exist in v24.
• HCC 2 and model version v28, the gap is accepted.
• HCC 8 and model version v28, the gap is rejected because HCC 8 does not exist in v28.
• HCC 2 and no model version, the gap is accepted for v28.
• HCC 37 and no model version, the gap is accepted for v28.
• HCC 8 and no model version, the gap is rejected because HCC 8 does not exist in v28.

 

Risk adjustment factors and blended scoring

 

Through 2024, while the Patient Risk dashboard supports two CMS-HCC model versions (v24 and v28) concurrently, the RAF weights are considered from both v24 and v28 models in a blended manner.

 

The phased implementation of the risk score calculation over 3 years is as follows:

• CY 2023, payment year 2024: 67% of risk scores with the v24 model, and 33% of risk scores with the v28 model (phase 1 — 2023)
• CY 2024, payment year 2025: 33% of risk scores with the v24 model, and 67% of risk scores with the v28 model (phase 2 - 2024)
• CY 2025, payment year 2026: 100% of risk scores with the v28 model (phase 3 - 2025)

 

The following two examples illustrate how the blended risk score is calculated.

 

Example 1

A 61-year-old female patient has four open potential diagnosis gaps. See the following tables for details on how the diagnosis gaps are displayed.

 

Open potential diagnosis gaps

• All diagnosis gaps are associated with both the v24 and v28 model versions. The HCC information of v28 is displayed along with the RAF weights.

 

Risk adjustment factor:

• The demographic factor of v28 is displayed in the Risk Adjustment Factors section.

• The risk score is calculated by blending the demographic factors of the v24 and v28 model versions.

 

Blended risk score calculation:

 

Closed diagnosis gaps

• The v24 RAF weights of all factors are added and 33% is applied to the sum

• The v28 RAF weights of all factors are added and 67% is applied to the sum

• Both values are added to get the blended score

• Only the v28 demographic factors are displayed in the Risk Adjustment Factors section.

 

Blended risk score calculation:

 

Example 2

A 61-year-old female patient has two open potential diagnosis gaps, one associated only with the v24 model version and the other associated with both v24 and v28. See the following tables for details on how the diagnosis gaps are displayed.

 

Open potential diagnosis gaps

 

Blended risk score calculation:

 

Closed diagnosis gaps

 

Blended risk score calculation:

 

There are several reports that you can use to assess your organization's performance against these metrics and assist with pre-visit planning.

You can find the reports in the Clinicals tab of the Report Library. You can use the Activate Reports page to activate these reports for your organization.

The following table outlines the goals and purpose of each report and the metric the report is designed to help track. You can filter these reports by payer, provider, department, and HCC (when applicable). We recommend running these reports on a regular basis to gain a better understanding of how well your organization is utilizing the features in athenaClinicals and documenting diagnoses on claims.

Note: The data in the Patient Risk dashboard is calculated in real time, whereas the data in the report is 1 day old. In some cases, the data in the dashboard and report may not match.

Diagnosis gap data is also available for in-depth analysis via Data View.

For more details on Data View, see the Data View Documentation on the Success Community.

For diagnoses from athenaOne claims to be considered for risk adjustment, the claim must meet the following criteria:

• Have at least one eligible CPT/HCPCS code. For more information, see the following CMS resource: Medicare Risk Adjustment Eligible CPT/HCPCS Codes)
• Have a supported place of service. For more details, see Supported places of service for HCC diagnosis gaps.

Note: Self-pay claims are not considered for risk adjustment.

Supported places of service for HCC diagnosis gaps

 

As of April 2024, athenahealth's HCC engine supports claims from the following places of service:

 

Place of service code	Place of service name
01	PHARMACY
02	TELEHEALTH – OTHER
05	INDIAN HEALTH SERVICE FREE-STANDING FACILITY
06	INDIAN HEALTH SERVICE PROVIDER-BASED FACILITY
07	TRIBAL 638 FREE-STANDING FACILITY
08	TRIBAL 638 PROVIDER-BASED FACILITY
09	PRISON - CORRECTIONAL FACILITY
10	TELEHEALTH - PATIENTS HOME
11	OFFICE
12	PATIENTS HOME
13	ASSISTED LIVING
14	GROUP HOME
16	TEMPORARY LODGING
17	WALK-IN RETAIL HEALTH CLINIC
19	OFF CAMPUS-OUTPATIENT HOSPITAL
20	URGENT CARE FACILITY
21	INPATIENT HOSPITAL
22	ON CAMPUS-OUTPATIENT HOSPITAL
23	EMERGENCY ROOM
24	AMBULATORY SURGICAL CENTER
25	BIRTHING CENTER
26	MILITARY TREATMENT FACILITY
31	SKILLED NURSING FACILITY
32	NURSING FACILITY
50	FEDERALLY QUALIFIED HEALTH CENTER
51	PSYCHIATRIC FACILITY - INPATIENT
52	PSYCHIATRIC FACILITY - OUTPATIENT
53	COMMUNITY MENTAL HEALTH CENTER
58	NON-RESIDENTIAL OPIOID TREATMENT FACILITY
61	COMPREHENSIVE INPATIENT REHABILITATION FACILITY
62	COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY
71	STATE OR LOCAL PUBLIC HEALTH CLINIC
72	RURAL HEALTH CLINIC

 

Our reconciliation logic appropriately surfaces CMS-HCC gaps and non-CMS-HCC gaps to ensure the Patient Risk dashboard does not display previously closed diagnosis gaps or duplicate diagnoses from different sources or models.

See the following reconciliation logic details:

• When athenaOne receives the same diagnosis attributed to different risk models, the diagnosis gap displays based on the following logic in the Patient Risk dashboard: CMS-HCC > HHS-HCC > CDPS.

• When athenaOne receives the same diagnosis gap in different states (for example, closed and open), the displayed state in the Patient Risk dashboard is based on the following logic: CLOSED > DISMISSED > OPEN.

• When athenaOne receives the same diagnosis as a potential and suspected gap, the diagnosis displays in the Potential Diagnoses section in the Patient Risk dashboard.

• When athenaOne receives the same diagnosis from multiple sources, the displayed source in the Patient Risk dashboard is based on the following logic: MANUAL > CLAIM > EXTERNAL (payers and other third parties).

• The Patient Risk dashboard also applies CMS-HCC Disease Hierarchy trumping logic. Within an HCC, we only display the higher specific HCC and one ICD-10 code. ICD-10 codes in two HCCs in the CMS-HCC model display the HCC with the higher RAF weight.

See the following table for various scenarios and the logic rules and details:

Scenario	Display logic rules	Display logic details
Multiple diagnoses	Diagnoses in multiple states	When athenaOne receives the same diagnosis in different states (for example, closed and open), the displayed state in the Patient Risk dashboard is based on the following logic: CLOSED > DISMISSED > OPEN.
	Different types of gaps	When athenaOne receives the same diagnosis as a potential and suspected diagnosis gap, the diagnosis displays in the Potential Diagnoses section in the Patient Risk dashboard.
	Diagnoses from different sources	When athenaOne receives the same diagnosis from multiple sources, the displayed source in the Patient Risk dashboard is based on the following logic: MANUAL > CLAIM > EXTERNAL (payers and other third parties).
	Diagnoses from multiple models	When athenaOne receives the same diagnosis attributed to different risk models, the diagnosis gap will display model details using the following hierarchy logic in the Patient Risk dashboard: CMS-HCC > HHS-HCC > CDPS.
	Multiple diagnoses within the same HCC	When athenaOne receives two different ICD-10 codes within the same HCC category, the most recent/latest diagnosis gaps we receive will display in the Patient Risk dashboard.
	Multiple diagnoses from the same source	When athenaOne receives the same diagnosis multiple times from the same sources, the displayed source in the Patient Risk dashboard is based on the following logic: MANUAL: the last user to add the diagnosis. CLAIM: the most recent claim. EXTERNAL (payers and other third parties): the first external source we received the gap from.
Different CMS-HCC model versions	Display a single model version for a diagnosis	If the ICD-10 code belongs to the v24 model only, the Patient Risk dashboard displays the ICD-10 code with the v24 HCC.   If the ICD-10 code belongs to v28 model only, the Patient Risk dashboard displays the ICD-10 code with the v28 HCC.   If the ICD-10 code belongs to the v24 and v28 HCC, the Patient Risk dashboard displays the ICD-10 code with the v28 HCC.
ICD-10 codes that map to multiple HCCs	Display a single HCC for an ICD-10 code	The Patient Risk dashboard displays the higher specific HCC for a diagnosis. ICD-10 codes associated with two HCCs in the CMS-HCC model display the HCC with the higher RAF weight. For example, for the E13.3411 ICD-10 code, the Patient Risk dashboard will display only HCC 298 – Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage (RAF weight 0.336), even though the code also maps to HCC 37 – Diabetes with Chronic Complications (RAF weight 0.166).   Note: In 2025, we plan to display all relevant HCCs for an ICD-10 code within the Patient Risk dashboard (meaning we would display both HCC 298 and HCC 37 for E13.3411 in the Potential Diagnoses section). However, we will continue to follow the CMS-HCC model and show only the higher HCC as closed.
CMS-HCC hierarchy rules	Disease hierarchy logic	We follow the CMS-HCC hierarchy/trumping logic where the Patient Risk dashboard displays only the ICD-10 codes for the higher severity HCC within a disease hierarchy and model version. For example: The Patient Risk dashboard displays the ICD-10 code for HCC 55 v24 over an ICD-10 code for HCC 56 v24. The Patient Risk dashboard displays the ICD-10 code for HCC 138 v28 over an ICD-10 code for HCC 137 v28   If the ICD-10 code belongs to the v24 and v28 models and is within a disease hierarchy, the Patient Risk dashboard displays the ICD-10 code with the highest severity HCC from v28.   We consider the HCC as closed for the year if one ICD-10 code within the category is submitted on a claim.
HCC configuration rules	HCC exclusions	If an HCC (v24 or v28) is excluded on the HCC Configuration clinicals admin page (Settings > Clinicals > HCC Configuration), any diagnoses associated with that HCC do not display for recapture in the Patient Risk dashboard.

Providers can reinstate dismissed diagnosis gaps as open gaps. If no action is taken to reinstate a dismissed diagnosis gap, the gap remains in the dismissed state for various periods of time depending on the source of the gap.

See the following table for more details:

A provider can dismiss a diagnosis gap if that clinical condition is found to be irrelevant for the patient. Dismissed diagnosis gaps appear in the Dismissed Diagnoses section of the Patient Risk dashboard. If the dismissed condition is later found to be relevant for the patient, the provider can reinstate the diagnosis gap as an open gap by clicking the Reinstate icon or by manually adding that diagnosis in the Patient Risk dashboard.

While a diagnosis gap (potential or suspected) is considered dismissed, the Patient Risk dashboard can receive the same gap from multiple sources. The system behavior in each of these scenarios is detailed in the following table: