Da Vinci Risk Adjustment Implementation Guide
2.0.0 - STU2 United States of America flag

Da Vinci Risk Adjustment Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-ra/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

Risk Adjustment Data Submission Client Capability Statement

This profile defines the expected capabilities of a Da Vinci Risk Adjustment Data Submission Client when conforming to the Da Vinci Risk Adjustment Implementation Guide for interactions between Data Submission Clients and Data Submission Servers. Clients are the actors creating and submitting the Risk Adjustment Data Exchange Measure Reports using the $submit-data operation to the Server.

Risk Adjustment Data Submission Server Capability Statement

This profile defines the expected capabilities of a Da Vinci Risk Adjustment Data Submission Server when conforming to the Da Vinci Risk Adjustment Implementation Guide for interactions between Clients and Servers. Servers are the actors receiving and processing the Risk Adjustment Data Exchange MeasureReports submitted by the Client.

Risk Adjustment Reporting Client Capability Statement

This profile defines the expected capabilities of a Da Vinci Risk Adjustment Reporting Client when conforming to the Da Vinci Risk Adjustment Implementation Guide for interactions between Reporting Clients and Reporting Servers. Clients are the actors making the request for Risk Adjustment Coding Gap Reports for patient(s) and for Risk Adjustmenet Models that are available on the Server. This CapabilityStatement resource includes the complete list of the recommended Da Vinci Risk Adjustment profiles and RESTful operations that a Risk Adjustment Reporting Client could support. Clients have the option of choosing from this list based on their local use cases and other contextual requirements.

Risk Adjustment Reporting Server Capability Statement

This profile defines the expected capabilities of a Da Vinci Risk Adjustment Reporting Server when conforming to the Da Vinci Risk Adjustment Implementation Guide for interactions between Reporting Clients and Reporting Servers. Servers are the actors receiving the request for Risk Adjustment Coding Gap Reports for patient(s) and for Risk Adjustmenet Models that are available on the Server. This CapabilityStatement resource includes the complete list of the recommended Da Vinci Risk Adjustment profiles and RESTful operations that a Risk Adjustment Reporting Server could support. Servers have the option of choosing from this list based on their local use cases and other contextual requirements.

Behavior: Operation Definitions

These are custom operations that can be supported by and/or invoked by systems conforming to this implementation guide.

Evaluate Measure

The ra.evaluate-measure operation is used to evaluate Digital Condition Category and obtain the results.

Behavior: Search Parameters

These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.

measurereport-category

Search based on the measurereport-category extension

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

Patient Group

The Patient Group Profile describes a group consisting of one or more patients. It can be used a) when generating risk adjustment gap reports using Bulk FHIR or b) for the evaluated-approach for generating reports as defined on the dCC page.

RA Parameters ccRemark Patch Profile

A Parameters profile that defines structures of multi-part Parameters to be used for sending Condition Category Remarks to a Risk Adjustment Coding Gap Report using the PATCH operation.

Risk Adjustment Coding Gap MeasureReport

This profile is based on the MeasureReport to represent a risk adjustment coding gap report. Payer runs risk adjustment engine and uses this profile to represent the risk adjustment Condition Category (CC) coding gaps and their detailed information for a patient.

Risk Adjustment Coding Gap Report Bundle

The Risk Adjustment Coding Gap Report Bundle Profile describes a collection bundle returned by the $ra.evaluate-measure operation. This bundle is a collection of Risk Adjustment Coding Gap Reports.

Risk Adjustment Data Exchange MeasureReport

This profile is based on the MeasureReport. It is used for Provider to submit data such as clinical evaluation evidence to Payer.

Risk Adjustment Model Measure

This risk adjustment model measure profile is based on the Measure resource to represent a risk adjustment model and its version, such as CMS-HCC version 24, CMS-HCC version 28.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

Condition Category Remark

The Condition Category Remark extension allows a coded and/or narrative remark be added to a Condition Category (CC) coding gap that is on a Payer generated risk adjustment coding gap report by a provider, an organization, or a software.

Confidence Scale

A coded confidence scale, the degree of certainty, for a Condition Category (CC) coding gap presented in a Payer generated risk adjustment coding gap report.

Diagnosis Code

Diganosis code(s) of the condition, such as ICD-10 codes.

Evidence Status

Indicates whether a Condition Category (CC) coding gap is closed-gap, open-gap, invalid-gap, or pending based on the clinical evidence available for risk adjustment.

Group Reference

This extension identifies which Condition Category (CC) the supporting evidence (represented by MeasureReport.evaluatedResource) is for.

Hierarchical Status

Indicates how hiearchies were applied to a Condition Category (CC), and if applied, whether the Condition Category (CC) is superseded.

Payer Coding Gap Report Id

Unique id of the original payer generated coding gap report. This is the MeasureReport.id from the Risk Adjustment Coding Gap Report profile.

Reporting Vendor Extension

A reference to the vendor who generated the report. The ‘reporting vendor’ is intended to represent the submitting entity when it is not the same as the reporting entity. This extension is used when the Receiver is interested in getting vendor information in the report.

Risk Adjustment Clinical Data Collection Deadline

Indicates the deadline for collecting data to close Condition Category (CC) coding gaps for a risk adjustment model of a measurement period.

Risk Adjustment Condition Category Type

Indicates whether the Condition Category (CC) gap is historic or suspected. This extension is also used to indicate if a Condition Category (CC) is net-new.

Risk Adjustment Evidence Status Date

Risk adjustment evidence status date

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Coding Gap Remark

Coded remark for a coding gap

Confidence Scale Value Set

Codes that describe the confidence scale of a risk adjustment Condition Category (CC).

Remark Reason

Reason for the remark

Risk Adjustment Condition Category Type ValueSet

Codes that indicate whether the Condition Category (CC) gap is historic, suspected, or net-new.

Risk Adjustment Evidence Status ValueSet

Codes that indicate whether a coding gap is an open-gap, invalid-gap, closed-gap, or pending.

Risk Adjustment Hierarchical Status ValueSet

Codes that indicate how hiearchies were applied to a Condition Category (CC), and if applied, whether the Condition Category (CC) is superseded.

Sample CMS Hierarchical Condition Category

This is a sample of the concepts that can be found in the CMS Hierarchical Condition Categories (CMS-HCC) code system version 24. The source of the codes included in this example was published at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2020.pdf. The CMS-HCC model uses more than 9,000 ICD-10-CM codes, which are mapped to condition categories (CCs) that predict costs well. The condition categories (CCs) are based on diagnoses clinically related to one another and with similar predicted cost implications. Hierarchies are imposed on the Condition Categories (CCs) to capture the most costly diagnoses. Hierarchy logic is imposed on certain Condition Categories (CCs) to account for different hierarchical costs, thus, the term Hierarchical Condition Category, or HCC.

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

Coding Gap Remark CodeSystem

Coded remark for coding gap

Remark Reason CodeSystem

Reason codes for remark

Risk Adjustment Condition Category Type CodeSystem

Code sytstem that indicates whether it is a suspected Condition Category (CC) gap, a historic Condition Category (CC) gap, or a net-new Condition Category (CC). Historic, suspected, and net-new are mutually exclusive.

Risk Adjustment Evidence Status CodeSystem

Code system that indicates whether a coding gap is an open-gap, invalid-gap, closed-gap, or pending.

Risk Adjustment Hierarchical Status CodeSystem

Code system that indicates how hierarchies were applied to a Condition Category (CC), and if applied, whether the Condition Category (CC) is superseded.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

Condition01pat03: Other artificial openings of gastrointestinal tract status

Other artificial openings of gastrointestinal tract status

Condition02pat01: Diabetes mellitus due to underlying condition with other diabetic kidney complication

Diabetes mellitus due to underlying condition with other diabetic kidney complication

Condition03pat01: Chronic obstructive pulmonary disease with (acute) exacerbation

Chronic obstructive pulmonary disease with (acute) exacerbation

Condition04pat03: Chronic obstructive pulmonary disease with (acute) exacerbation

Chronic obstructive pulmonary disease with (acute) exacerbation

Condition05pat03: Unspecified protein-calorie malnutrition

Unspecified protein-calorie malnutrition

Condition06pat03: Crohn's disease of large intestine with unspecified complicationss

Crohn’s disease of large intestine with unspecified complications

Condition07pat03: Other persistent atrial fibrillation

Other persistent atrial fibrillation

Condition08pat01: Bipolar disorder, current episode mixed, mild

Bipolar disorder, current episode mixed, mild

Condition09pat01: Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis

Condition10pat01: Long term (current) use of insulin

Long term (current) use of insulin

Condition11pat01: Acute pulmonary edema

Acute pulmonary edema

Condition12pat01: Manic episode, unspecified

Manic episode, unspecified (clinical evaluation evidence)

Condition15pat03: Diabetes mellitus due to underlying condition with diabetic chronic kidney diseases

Diabetes mellitus due to underlying condition with diabetic chronic kidney diseases

Condition16pat03: Dependence on renal dialysis

Dependence on renal dialysis

Condition17pat01: Body mass index [BMI] 45.0-49.9, adult

Body mass index [BMI] 45.0-49.9, adult

Condition18pat01: Longstanding persistent atrial fibrillation

Longstanding persistent atrial fibrillation

Condition21pat03: Type 2 diabetes mellitus without complications

Type 2 diabetes mellitus without complications

Condition22pat03: Other acute kidney failure

Other acute kidney failure

Condition23pat03: Chronic kidney disease, stage 5

Chronic kidney disease, stage 5

Condition31pat02: Typical atrial flutter

Typical atrial flutter

Condition32pat03: Chronic pulmonary embolism

Chronic pulmonary embolism

Condition33pat01: Respiratory arrest

Respiratory arrest

Condition35pat03: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

Condition42pat03: Other artificial openings of gastrointestinal tract status

Other artificial openings of gastrointestinal tract status

Condition43pat01: Diabetes mellitus due to underlying condition with other diabetic kidney complication

Diabetes mellitus due to underlying condition with other diabetic kidney complication

Condition44pat01: Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis

ConditionR01pat01: Cystic fibrosis with other intestinal manifestations

Cystic fibrosis with other intestinal manifestations

Documentreference01pat01: Outpatient Note

Outpatient Note

Encounter on 20170118

Encounter on 2017-01-18

Encounter on 20170203

Encounter on 2017-02-03

Encounter on 20180721

Encounter on 2018-07-21

Encounter on 20190207

Encounter on 2019-02-07

Encounter on 20190210

Encounter on 2019-02-10

Encounter on 20200210

Encounter on 2020-02-10

Encounter on 20200303

Encounter on 2020-03-03

Encounter on 20200808

Encounter on 2020-08-08

Encounter on 20200917

Encounter on 2020-09-17

Encounter on 20201102

Encounter on 2020-11-02

Encounter on 20201218

Encounter on 2020-12-18

Encounter on 2021-10-15

Encounter on 2021-10-15 (clinical evaluation evidence)

Encounter on 20210130

Encounter on 2021-01-30

Encounter on 20210131

Encounter on 2021-01-31

Encounter on 20210212

Encounter on 2021-02-12

Encounter on 20210327

Encounter on 2021-03-27

Encounter on 20210701

Encounter on 2021-07-01

Encounter on 20210714

Encounter on 2021-07-14

Encounter on 20210727

Encounter on 2021-07-27

Encounter on 20210806

Encounter on 2021-08-06

Encounter on 20210823

Encounter on 2021-08-23

Encounter on 20210926

Encounter on 2021-09-26

Laboratory01: XYZ Laboratory

XYZ Laboratory

Observation: Creatinine Result from 20210728

Creatinine Result from 2021-07-28

Observation: PHQ9 from 20190823

PHQ9 from 2019-08-23

Observation: Trypsin [Mass/volume] in Serum or Plasma result from 20190617

Trypsin [Mass/volume] in Serum or Plasma result from 2019-06-17

Organization01: ABC Payer

ABC Payer

Organization: Community HealthCenter

Community HealthCenter

Organization: Community Urgent Care

Community Urgent Care

Organization: GHH Outpatient Clinic

GHH Outpatient Clinic

Organization: Risk Adjustment Author

Risk Adjustment Author

Patient01: Eve Everywoman

Eve Everywoman

Patient02: Adam Everyman

Adam Everyman

Patient03: Nelda Nuclear

Nelda Nuclear

Practitioner: Harold Hippocrates

Harold Hippocrates

Practitioner: Otto Osler

Otto Osler

Practitioner: Patrick Pump

Patrick Pump

Risk Adjustement Measure Report Patch

Patch of a Risk Adjustement Measure Report

Risk Adjustement Measure Report Patch With Multiple Values

Patch of multiple values for a Risk Adjustement Measure Report

Risk Adjustment Model Version 21 - CMS Hierarchical Category Condition (CMS-HCC)

Example measure to represent CMS-HCC Model Version 21

Risk Adjustment Model Version 24 - CMS Hierarchical Category Condition (CMS-HCC)

Example measure to represent CMS-HCC Model Version 24

Risk Adjustment Model Version 5 - CMS Prescribing Drug Hierarchical Category Condition (CMS-HCC)

Example measure to represent CMS-RxHCC Model Version 5

Submit Data for Risk Adjustement Data Exchange MeasureReport

Example Parameters Resource for using submit-data operation to submit Risk Adjustment Data Exchange MeasureReport

Trypsin [Mass/volume] in Serum or Plasma from 20170617

Trypsin [Mass/volume] in Serum or Plasma from 2017-06-17

Vendor01: Best RA Vendor

Best RA Vendor

ra-bundle01: Risk Adjustment Bundle

Example Risk Adjustment Bundle

ra-datax-measurereport01: Risk Adjustment Data Exchange Measure Report

Example Risk Adjustment Data Exchange Measure Report

ra-group01: Risk Adjustment Patient Group

Example Risk Adjustment Group

ra-group02: Risk Adjustment Patient Group

Example Risk Adjustment Group

ra-measurereport01-with-remark: Risk Adjustment Measure Report with Condition Category Remark

Example Risk Adjustment Measure Report with Condition Catetory Remark

ra-measurereport01: Risk Adjustment Measure Report

Example Risk Adjustment Measure Report

ra-measurereport02: Risk Adjustment Measure Report

Example Risk Adjustment Measure Report

ra-measurereport03: Risk Adjustment Measure Report for HCC V24 for Patient 02

Example Risk Adjustment Measure Report for HCC V24 for Patient 02

ra-measurereport04: Risk Adjustment Measure Report for HCC V21 for Patient 03

Example Risk Adjustment Measure Report for HCC V21 for Patient 03

ra-measurereport05: Risk Adjustment Measure Report for RxHCC V5 for Patient03

Example Risk Adjustment Measure Report for RxHCC V5 for Patient03

ra-measurereport06: Risk Adjustment Measure Report for RxHCC V5 for Patient02

Example Risk Adjustment Measure Report for RxHCC V5 for Patient02