This profile defines the expected capabilities of a Da Vinci Risk Adjustment Remediation Client when conforming to the Da Vinci Risk Adjustment Implementation Guide for interactions between Remediation Clients and Remediation Servers. Clients are the actors making the request for remediating Risk Adjustment coding gaps for Risk Adjustment Coding Gap Reports of patient(s) that are available on the Server.

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.

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.

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.

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

The Patient Group Profile describes a group consisting of one or more patients.

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.

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.

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

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.

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.

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.

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

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

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how hiearchies were applied to a Condition Category (CC), and if applied, whether the Condition Category (CC) is superseded.

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

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.

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

Risk adjustment evidence status date

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.

Suggested conditions by suspecting.

Coded remark for a coding gap

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

Reason for the remark

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

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how hiearchies were applied to a Condition Category (CC), and if applied, whether the Condition Category (CC) is superseded.

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

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.

Coded remark for coding gap

Reason codes for remark

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

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

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.

Other artificial openings of gastrointestinal tract status

Diabetes mellitus due to underlying condition with other diabetic kidney complication

Chronic obstructive pulmonary disease with (acute) exacerbation

Chronic obstructive pulmonary disease with (acute) exacerbation

Unspecified protein-calorie malnutrition

Crohn’s disease of large intestine with unspecified complications

Other persistent atrial fibrillation

Bipolar disorder, current episode mixed, mild

Allergic bronchopulmonary aspergillosis

Long term (current) use of insulin

Acute pulmonary edema

Manic episode, unspecified (clinical evaluation evidence)

Diabetes mellitus due to underlying condition with diabetic chronic kidney diseases

Dependence on renal dialysis

Body mass index [BMI] 45.0-49.9, adult

Longstanding persistent atrial fibrillation

Type 2 diabetes mellitus without complications

Other acute kidney failure

Chronic kidney disease, stage 5

Typical atrial flutter

Chronic pulmonary embolism

Respiratory arrest

Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

Other artificial openings of gastrointestinal tract status

Diabetes mellitus due to underlying condition with other diabetic kidney complication

Allergic bronchopulmonary aspergillosis

Cystic fibrosis with other intestinal manifestations

Outpatient Note

Encounter on 2017-01-18

Encounter on 2017-02-03

Encounter on 2018-07-21

Encounter on 2019-02-07

Encounter on 2019-02-10

Encounter on 2020-02-10

Encounter on 2020-03-03

Encounter on 2020-08-08

Encounter on 2020-09-17

Encounter on 2020-11-02

Encounter on 2020-12-18

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

Encounter on 2021-01-30

Encounter on 2021-01-31

Encounter on 2021-02-12

Encounter on 2021-03-27

Encounter on 2021-07-01

Encounter on 2021-07-14

Encounter on 2021-07-27

Encounter on 2021-08-06

Encounter on 2021-08-23

Encounter on 2021-09-26

XYZ Laboratory

Creatinine Result from 2021-07-28

PHQ9 from 2019-08-23

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

ABC Payer

Community HealthCenter

Community Urgent Care

GHH Outpatient Clinic

Risk Adjustment Author

Eve Everywoman

Adam Everyman

Nelda Nuclear

Harold Hippocrates

Otto Osler

Patrick Pump

Patch of a Risk Adjustement Measure Report

Patch of multiple values for a Risk Adjustement Measure Report

Example measure to represent CMS-HCC Model Version 21

Example measure to represent CMS-HCC Model Version 24

Example measure to represent CMS-RxHCC Model Version 5

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

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

Best RA Vendor

Example Risk Adjustment Bundle

Example Risk Adjustment Data Exchange Measure Report

Example Risk Adjustment Group

Example Risk Adjustment Group

Example Risk Adjustment Measure Report with Condition Catetory Remark

Example Risk Adjustment Measure Report

Example Risk Adjustment Measure Report

Example Risk Adjustment Measure Report for HCC V24 for Patient 02

Example Risk Adjustment Measure Report for HCC V21 for Patient 03

Example Risk Adjustment Measure Report for RxHCC V5 for Patient03

Example Risk Adjustment Measure Report for RxHCC V5 for Patient02