Support for Use of Encounter Data in Overpayment Reruns

Relevant to: All Medicare Advantage, Cost, PACE and Demonstration Organization Systems Staff

On February 29, 2024, the Centers for Medicare & Medicaid Services (CMS) released an HPMS memo entitled “2024 Risk Score Reruns for Purposes of Payment Recovery.” As discussed in that memo, CMS will be taking into account diagnoses deleted from the encounter data system (“encounter data deletes”) in the processing of overpayments starting this year. We have received a number of questions regarding how deleted diagnoses are reported back to submitters. As part of our efforts to respond to these inquires and support Medicare Advantage (MA) organizations and other entities that submit risk adjustment data, CMS is sending this memo to describe how to identify deleted diagnoses using CMS reports. We also provide a compilation of existing resources to support MA and other organizations in understanding the risk adjustment eligibility status of the diagnoses they submit to the encounter data system.

See the full guidance for more information.