Questions and Answers
NYS Medicaid Grouper
| Question Number | Question | Answer |
|---|---|---|
| 1 | Will DOH or a 3rd party distribute a grouper module or will vendors/providers need to write their own? | NYS will not be distributing a grouper module. Providers will need to create their own module which will generate one of the 108 rate codes to be used to bill on the Medicaid claim. |
| 2 | What technology will the grouper module be developed in (java, .net, dll, etc.) | The technology used for development of the module is a provider decision. |
| 3 | What are the grouper variables and how are they factored in? | Age, clinical, functional, and type of assessment are the four components in determining group. |
| 4 | The HIV group includes the code group 795.8 Abnormal Tumor Markers. This code requires 5 digits. Does DOH plan to include all codes with the first 4 digits of 795.8? In the other groups DOH specified the 5 digit codes. There are 3 codes in that group and they were valid in 2009: 795.81 elevated carcinoembryonic antigen (CEA) 795.82 Elevated Cancer antigen 125 (CA125) 795.89 Other abnormal tumor markers |
From 1986 to 1994, '7958' was a valid code for HIV Infection - Positive Sero/Viral HIV. So, '7958' is valid, if it appears. '79581', '79582', '79589' are not valid codes for HIV Infection. |
| 5 | Are the diagnosis codes referred to in the SAS the primary only, the primary and the next X number of diagnosis codes associated with the assessment? There are 6 diagnosis codes associated with an assessment; do we interrogate all of the six for any of the category values for the Grouper? | When looking at the diagnosis codes you can look at all six (primary and 5 secondary) diagnosis codes listed in the assessment. |
| 6 | In the Medicare grouper there is a table of allowable pairings of etiology and manifestation codes. If these codes are not both listed the case mix points are not awarded in the calculation of the HHRG. I noted in the dementia codes the listing of 294.10, 294.11. These are both manifestation codes for the etiologies codes: 331.0, 331.11, 331.19 and 331.82. Will we need to code both to obtain the case mix points as in the case of the Medicare grouper? | No, the NYS Medicaid Grouper will not be looking for pairings of etiology and manifestation codes. |
| 7 | I am assuming only one code in a group will receive points in the grouper. For example the patient may have diabetes with a neurologic manifestation (250/6x) and diabetes with a peripheral circulatory manifestation (250.7x). In this situation am I correct in understanding I would receive 4 points only for both codes? | That is correct; a maximum of four points can be awarded for diabetes regardless of the number of diabetes related ICD-9 codes listed. Diabetes is valued at 4 points, Orthopedic is 2, Dementia is 24 and HIV is 10 points. If the patient has a dx of diabetes and HIV - that person would receive 14 points (4 +10). |
| 8 | Is it your intention that when a category ICD is listed, all the qualified codes are to be included? For example you list (ortho code 170), are you including 1700, 1701, 1702, 1703, 1704, 1705, 1706, 1708, 1709. Is the ICD code 29420 redundant since you list the category of 294? | Yes, if the category ICD is listed, it is assumed that all qualifying codes are included. |
| 9 | Going forward, as ICD codes are added that effect reimbursement, how and when would those updates be relayed? Will the NYMA grouper be updated to accommodate them? Will the October 1, 2011 ICD changes be used? Will ICD10 be factored when applicable? | Yes, ICD10 changes will be factored in if applicable. |
| 10 | What will happen to the calculation if the ICD on an episode is not on the list that is provided? | If the ICD is not part of the algorithm, it will not be counted. |
| 11 | When the next generation of OASIS is released, how quickly will NYMA update their system? | The episodic payment system will continue to be evaluated for changes in data elements and any other adjustments that may need to be applied to ensure the continued accuracy of the payment model in the evolving transition of patients to managed care. |
| 12 | What is the timeframe for completion of OASIS assessments? | Timeframes for completing the OASIS do not change and will continue to follow federal guidelines. |
