CMS Pub. 100-16, ch. 7, § 120.1

According to 42 CFR 422, MA organizations must collect and submit to CMS the data

necessary to characterize the context and purposes of each service provided to a Medicare

enrollee by a provider, supplier, physician, or other practitioner. CMS may also collect

data necessary to characterize the functional limitations of enrollees of each MA

organization.

120.1.1 - Sources of Data

(Rev. 118; Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012 (for ASC X12 5010); Implementation: ICD-10: Upon Implementation of ICD-10,

ASC X12: January 1, 2012 (for ASC X12 5010))

CMS requires that MA organizations collect data for the purposes of risk adjustment

from the following provider types:

• Hospital inpatient facilities

• Hospital outpatient facilities

• Physicians

Unacceptable Data Sources

It is important for MA organizations to note that regardless of the type of diagnostic

radiology bill (outpatient department or physician component), the diagnostic data

associated with these services are not acceptable for risk adjustment. Diagnostic

radiologists typically do not document confirmed diagnoses. The diagnosis confirmation

comes from referring physicians or physician extenders and is, therefore, not assigned in

the medical record documentation from diagnostic radiology services alone.

Excluded Providers

Medicare will not pay for items or services rendered to beneficiaries and recipients by an

excluded provider or by entities owned or managed by an excluded provider. Therefore,

MA organizations should not submit risk adjustment data if it was submitted by an

excluded provider. Providers are excluded for the following reasons: a program related

crime, patient abuse or neglect, health care fraud in any health care program, and

convictions relating to controlled substances.

The HHS monthly exclusion notification can be found at

http://oig.hhs.gov/fraud/exclusions.asp.

Hospital Inpatient

A hospital inpatient service is one provided by a hospital during which a patient is

admitted to the facility for at least one overnight stay. Table 13 identifies covered and

non-covered facilities with regard to risk adjustment diagnoses data collection.

Table 13. Hospital Inpatient Sources of Diagnostic Data

RAPS Provider

Type Covered Facilities Non-Covered Facilities*

Hospital

Inpatient

Short-term (general and specialty)

Hospitals

Religious Non-Medical Health

Care Institutions (formerly

Christian Science Sanatoria)

Long-term Hospitals

Rehabilitation Hospitals

Children’s Hospitals

Psychiatric Hospitals

Medical Assistance Facilities/

Critical Access Hospitals

Skilled Nursing Facilities (SNFs)

Hospital Inpatient Swing Bed

Components

Intermediate Care Facilities

Respite Care

Hospice

*These are examples of non-covered facilities and not a comprehensive list.

NOTE: When submitting hospital inpatient data, MA organizations must make a

distinction between the principal diagnosis and other diagnoses. Section 120.2

Submission and Flow of Risk Adjustment Data covers the details of submitting data.

Hospital Outpatient

Hospital outpatient services are therapeutic and rehabilitative services provided for sick

or injured persons who do not require inpatient hospitalization or institutionalization.

Table 14 identifies covered and non-covered hospital outpatient facilities. MA

organizations should refer to this table with regard to risk adjustment data collection.

Table 14. Outpatient Sources of Diagnostic Data

RAPS

Provider Type Covered Facilities Non-Covered Facilities*

RAPS

Provider Type Covered Facilities Non-Covered Facilities*

Hospital

Outpatient

Short-term (general and specialty)

Hospitals

Medical Assistance Facilities/Critical

Access Hospitals

Community Mental Health Centers 1**

Federally Qualified Health Centers 2/

Religious Non-Medical Health Care

Institutions (formerly Christian Science

Sanatoria) **

Long-term Hospitals

Rehabilitation Hospitals

Children’s Hospitals

Psychiatric Hospitals

Rural Health Clinic (Free-standing and

Provider-Based) 3**

Free-standing Ambulatory Surgical

Centers (ASCs)

Home Health Care

Free-standing Renal Dialysis

Facilities

Non-Covered Services

Laboratory Services

Ambulance

Durable Medical Equipment

Prosthetics

Orthotics

Supplies

Radiology Services

* These are examples of non-covered facilities and are not to be considered a

comprehensive list.

** Facilities use a composite bill that covers both the physician and the facility

component of the services, and services rendered in these facilities do not result in an

independent physician claim.

1. Community Mental Health Centers (CMHCs) provide outpatient services, including

specialized outpatient services for children, the elderly, individuals who are chronically

ill, and residents of the CMHC’s mental health services area who have been discharged

from inpatient treatment at an inpatient facility.

2. Federally Qualified Health Centers (FQHCs) are facilities located in a medically

underserved area that provide Medicare beneficiaries with preventive primary medical

care under the general direction of a physician.

3. Rural Health Clinics (RHCs) are Medicare certified facilities that are located in a

rural, medically underserved area that provide ambulatory primary medical care under the

general direction of a physician.

Determining Whether Facilities Are Acceptable for Risk Adjustment – MA

organizations are responsible for ensuring that data collected and submitted to CMS are

acceptable for the risk adjustment process. However, the NPI does not convey

information regarding the type of facility or provider specialty, so a new code called the

“taxonomy code” can be used to help identify types of providers. Both the legacy

provider number and the taxonomy code can be used in determining the appropriateness

of the covered hospital entities for the purposes of risk adjustment data collection. Table

15 illustrates the steps MA organizations may use to identify the provider numbers or

taxonomy codes for facilities.

Table 15. Determining Covered Hospital Entity Provider Numbers

Situation Issue Action

Situation 1 The CCN or taxonomy

code is identified.

Determine if the number is in an acceptable

range for risk adjustment. If in the

acceptable range, submit the data.

Situation 2 An in-network provider

submitted a claim but did

not include any provider

number or taxonomy

code.

Obtain the provider number or taxonomy

code and then determine if the number is in

an acceptable range for risk adjustment. If in

the acceptable range, submit the data.

NOTE: All network providers are required

to have provider numbers or taxonomy

codes; therefore, do not submit risk

adjustment data for this provider until these

numbers are obtained.

Situation 3 An out-of-network

provider submits a claim

without a provider

number.

Plans must obtain a provider number or

taxonomy code.

National Provider Identifier – MA organizations should verify that diagnoses are

collected from Medicare certified hospitals/facilities and that data from all Medicare

certified network hospital/facilities include the associated Medicare provider identifiers

(NPI and taxonomy code; or the legacy provider number). They should also verify that

the Medicare certified hospitals/facilities providing the data are from acceptable facilities

and services. As stated above, plans may use either the Medicare provider numbers or

the taxonomy code to determine if facilities and services are acceptable for risk

adjustment.

Plan sponsors may wish to create a system for checking if the data are from acceptable

facilities and for acceptable services. They may check the legacy provider number

against the provider number ranges or check the taxonomy code against the taxonomy

code ranges, both of which identify what type of service has been rendered.

• If using the legacy provider number, please note that it has six characters.

o The first two characters are numerals and represent the state/territory as

illustrated in Table 16.

Table 16. Provider Number State Assignments

State Code State Code State Code

Alabama 01 Kentucky 18 Oklahoma 37

Alaska 02 Louisiana 19 Oregon 38

American Samoa 64 Maine 20 Palau N/A

Arizona 03 Maryland 21 Pennsylvania 39

Arkansas 04 Massachusetts 22 Puerto Rico 40

California 05 Michigan 23 Rhode Island 41

Colorado 06 Minnesota 24 South Carolina 42

Connecticut 07 Mississippi 25 South Dakota 43

Delaware 08 Missouri 26 Tennessee 44

District of

Columbia

09 Montana 27 Texas 45

Florida 10 Nebraska 28 Utah 46

Georgia 11 Nevada 29 Vermont 47

Guam 65 New Hampshire 30 Virgin Islands 48

Hawaii 12 New Jersey 31 Virginia 49

Idaho 13 New Mexico 32 Washington 50

Illinois 14 New York 33 West Virginia 51

Indiana 15 North Carolina 34 Wisconsin 52

Iowa 16 North Dakota 35 Wyoming 53

Kansas 17 Ohio 36

o The third character may be a numeral or a letter. Provider numbers with a U,

W, Y, Z, 5, or 6 in the third character indicate that the service was provided in

a swing bed component of a hospital or a skilled nursing facility, which, are

not covered entities. The last three characters are numerals unique to the

facility.

• If using the taxonomy code, the bill type will be needed to identify if the service was

provided by a non-covered entity such as a swing bed component of a hospital or a

skilled nursing facility.

As an additional check, refer to Tables 17 and 18, which provide the only acceptable

ranges for hospital facilities. The tables reflect the range of legacy provider numbers for

risk adjustment covered hospital entities. Risk adjustment data are not acceptable when

received from facilities with numbers outside the ranges.

NOTE: Skilled nursing facilities, home health care, and hospital inpatient swing bed

components are not covered entities for risk adjustment data.

Table 17. Hospital Inpatient Covered Entities

Type Of Hospital Inpatient Facility Provider

Number Range

Taxonomy Code/

Type of Bill (TOB)

Short-term (General and Specialty) Hospital XX0001-

XX0899

XXS001-

XXS899

XXT001-

XXT899

282N00000X

273R00000X

273Y00000X

Medical Assistance Facilities/Critical Access

Hospitals

XX1225-

XX1399

282NC0060X

Religious Non-Medical Health Care

Institutions

XX1990-

XX1999

TOB 4XX

Long-term Hospitals XX2000-

XX2299

282E00000X

Rehabilitation Hospitals XX3025-

XX3099

283X00000X

Children’s Hospitals XX3300-

XX3399

282NC2000X

Psychiatric Hospitals XX4000-

XX4499

283Q00000X

Table 18. Hospital Outpatient Covered Entities

Type Of Hospital Outpatient Facility Provider Number

Range

Taxonomy Code/

Type of Bill (TOB)

Short-term (General and Specialty) Hospital XX0001-XX0899

XXS001-XXS899

XXT001-XXT899

282N00000X

273R00000X

273Y00000X

Medical Assistance Facilities/Critical Access

Hospitals

XX1225-XX1399 282NC0060X

Community Mental Health Centers XX1400-XX1499

XX4600-XX4799

XX4900-XX4999

TOB 76X

Federally Qualified Health Centers/Religious Non-Medical Health Care Institutions

XX1800-XX1999 TOB 73X for FQHC

TOB 4XX for RNHCI

Long-term Hospitals XX2000-XX2299 282E00000X

Rehabilitation Hospitals XX3025-XX3099 283X00000X

Children’s Hospitals XX3300-XX3399 282NC2000X

Type Of Hospital Outpatient Facility Provider Number

Range

Taxonomy Code/

Type of Bill (TOB)

Rural Health Clinics, Freestanding and Provider-Based

XX3400-XX3499

XX3800-XX3999

XX8500-XX8999

TOB 71X

Psychiatric Hospitals XX4000-XX4499 283Q00000X

The implementation of the NPI did not change the valid Hospital Inpatient and Outpatient

facilities for submission of risk adjustment data nor eliminate the process for receiving

and verifying information from Medicare health care providers that are in network.

Institutional providers that currently bill Medicare using more than one legacy identifier

in order to identify subparts of their facility are required to submit a taxonomy code on all

of the claims they submit to Medicare.

The Health Care Provider Taxonomy Code Set website,

http://www.wpc-edi.com/codes/taxonomy, serves as a reference to types of facilities and

taxonomy codes.

The American Hospital Directory website, http://www.ahd.com/freesearch.php3, serves

as a reference for hospital provider numbers.

Physician

The collection of physician data relevant for risk adjustment is associated with the

physician’s specialty. That is, all diagnoses that are in the risk adjustment model and

rendered as a result of a physician visit must be collected by the MA organization. This

includes data collected from non-network as well as network physicians.

Qualified physician data for risk adjustment requires a face-to-face visit with the

exception of pathology services (professional component only).

Only those physician specialties and other clinical specialists identified in Table 19 are

acceptable for risk adjustment.

Table 19. Acceptable Physician Specialty Types

Payment Year 2011 (dates of services 2010)

CODE SPECIALTY CODE SPECIALTY CODE SPECIALTY

1 General Practice 26 Psychiatry 67 Occupational

Therapist

2 General Surgery 27** Geriatric

Psychiatry 68 Clinical Psychologist

3 Allergy/Immunology 28 Colorectal Surgery 72* Pain Management

4 Otolaryngology 29 Pulmonary

Disease 76* Peripheral Vascular

Disease

5 Anesthesiology 33* Thoracic Surgery 77 Vascular Surgery

6 Cardiology 34 Urology 78 Cardiac Surgery

7 Dermatology 35 Chiropractic 79 Addiction Medicine

8 Family Practice 36 Nuclear Medicine 80 Licensed Clinical

Social Worker

9** Interventional Pain

Management (IPM) 37 Pediatric Medicine 81 Critical care

(intensivists)

10 Gastroenterology 38 Geriatric Medicine 82 Hematology

11 Internal Medicine 39 Nephrology 83 Hematology/Oncology

12

Osteopathic

Manipulative

Therapy

40 Hand Surgery 84 Preventive Medicine

13 Neurology 41 Optometry 85 Maxillofacial Surgery

14 Neurosurgery 42 Certified Nurse

Midwife 86 Neuropsychiatry

15 Speech Language

Pathologist 43

Certified

Registered Nurse

Anesthetist

89* Certified Clinical

Nurse Specialist

16 Obstetrics/Gynecolog

y 44 Infectious Disease 90 Medical Oncology

17** Hospice And

Palliative Care 46* Endocrinology 91 Surgical Oncology

18 Ophthalmology 48* Podiatry 92 Radiation Oncology

19 Oral Surgery 50* Nurse Practitioner 93 Emergency Medicine

20 Orthopedic Surgery 62* Psychologist 94 Interventional

Radiology

22* Pathology 64* Audiologist 97* Physician Assistant

24*

Plastic And

Reconstructive

Surgery

65 Physical Therapist 98 Gynecologist/Oncolog

ist

25 Physical Medicine

And Rehabilitation 66 Rheumatology 99 Unknown Physician

Specialty

* Indicates that a number has been skipped.

** Added effective January 1, 2010 dates of service