Risk Adjustment

This 3rd party API will facilitate publishing patient gaps periodically via interfaces from external partners and clients. Risk adjustment workflows are tightly coupled with the HCC risk adjustment model as every ingested risk gap is validated against the HCC risk adjustment model and deduped. HCC compliant risk gaps will be eligible to surface in the Athena Risk Adjustment workflow. Gaps that are irrelevant as per the HCC specification will be ignored. Disease hierarchy exclusions are to be considered as relevant. 3rd party gaps will be surfaced as a potential or suspected diagnosis as appropriate in the Patient Risk dashboard. Providers should be able to take action on risk gaps during the encounter workflow.

Segregation of Risk Gaps Based on Clinical & Verification Status:

Risk Gaps State Clinical Status Verification Status
Potential
(Clinically verified)
relapse differential
Suspected
(Clinically inferred)
relapse provisional

Supported Evidence Acceptable Codes for Suspected Risk Gaps:

Athena Reference Supporting Evidence Code
Medication Statement
Procedure
Diagnostic Reports
Claim
Basic (custom extension)
  • Provider Speciality ("valueString":"SPC")
  • Notes
Note: Evidences are only valid for Suspected Risk Gaps

Mandatory HTTP Request Headers:

  • Content-Type: application/x-www-form-urlencoded
  • X-PARTNER-CODE: <<partner>>
    • CODE is used to identify the partner. This will be displayed to the user as the source of the risk gaps.

Example Code:

Sample Curl Template for a Potential Condition

curl --location --request POST 'https://api.preview.platform.athenahealth.com/v1/your_context_id/riskgaps/condition' \
--header 'X-PARTNER-CODE: your_partner_name' \
--header 'Authorization: Bearer your_token' \
--header 'Content-Type: application/x-www-form-urlencoded' \
--data-urlencode 'entry=[{"resource":{"resourceType":"condition","identifier":[{"system":"https://partner-site-name.com","value":"62545"}],"subject":{"reference":"#Pat1234"},"code":{"coding":[{"system":"http://hl7.org/fhir/sid/icd-10","code":"E1122","display":""}]},"clinicalStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/condition-clinical","code":"relapse"}]},"verificationStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/condition-ver-status","code":"differential"}]},"encounter":{"reference":"#Enc1"},"recorder":{"reference":"#Prac7890"},"contained":[{"resourceType":"Patient","id":"Pat1234","identifier":[{"system":"https://athenanet.athenahealth.com/patient","value":"500"},{"system":"https://athenanet.athenahealth.com/chartsharinggroup","value":"21"}]},{"resourceType":"Practitioner","id":"Prac7890","identifier":[{"system":"https://athenanet.athenahealth.com/practitioner","value":"45627"}],"name":[{"text":"Dr. Who"}]},{"resourceType":"Encounter","id":"Enc1","period":{"start":"2021-05-23"},"location":[{"location":{"reference":"#Location5678","display":"location Where"}}]}]},"request":{"method":"POST"}}]'

Sample Curl Template for a Suspected Condition

curl --location --request POST 'https://api.preview.platform.athenahealth.com/v1/your_context_id/riskgaps/condition' \
--header 'X-PARTNER-CODE: your_partner_name' \
--header 'Authorization: Bearer your_token' \
--header 'Content-Type: application/x-www-form-urlencoded' \
--data-urlencode 'entry=[{"fullUrl":"urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0sss","resource":{"resourceType":"Condition","identifier":[{"system":"https://partner-site-name.com","value":"62545"}],"clinicalStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/condition-clinical","code":"relapse"}]},"verificationStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/condition-ver-status","code":"provisional"}]},"code":{"coding":[{"system":"https://www.cms.gov/hcc","code":"1"}]},"subject":{"reference":"#Pat1053"},"recordedDate":"2021-05-13T11:07:36-06:00","recorder":{"reference":"#Prac7890"},"evidence":[{"detail":[{"reference":"#MedicationStatement57676003"},{"reference":"#Procedure2"},{"reference":"#DiagnosticReport10"},{"reference":"#Claim100150"},{"reference":"#Basic10"},{"reference":"#Basic11"}]}],"contained":[{"resourceType":"Patient","id":"Pat1053","identifier":[{"system":"https://athenanet.athenahealth.com/patient","value":"2974"},{"system":"https://athenanet.athenahealth.com/chartsharinggroup","value":"21"}]},{"resourceType":"Organization","id":"999","identifier":[{"system":"https://athenanet.athenahealth.com/organization"}],"name":[{"text":"ELMHURST MEMORIAL HOSPITAL"}]},{"resourceType":"Practitioner","id":"Prac7890","identifier":[{"system":"https://athenanet.athenahealth.com/practitioner","value":"45627"}],"name":[{"text":"Dr. SK "}]},{"resourceType":"MedicationStatement","id":"MedicationStatement57676003","identifier":[{"system":"https://athenanet.athenahealth.com/MedicationStatement","value":"132132123"}],"outcome":"complete","informationSource":{"reference":"Organization/999"},"status":"active","effectiveDateTime":"2021-08-13T11:07:36-06:00","medicationCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/sid/ndc","code":"ERT780","display":"Display this condition"}]}},{"resourceType":"Procedure","id":"Procedure2","identifier":[{"system":"https://partner-site-name.com","value":"121212"}],"status":"preparation","performer":[{"actor":"Organization/999"}],"subject":{"reference":"Patient/1053"},"performedDateTime":"2020-10-10","code":{"coding":[{"system":"http://hl7.org/fhir/sid/ex-icd-10-procedures","code":"70450","display":"Computed tomography, head or brain; without contrast material"}]}},{"resourceType":"DiagnosticReport","id":"DiagnosticReport10","identifier":[{"system":"https://partner-site-name.com","value":"3322"}],"status":"registered","performer":[{"reference":"Organization/999"}],"issued":"2011-03-04T11:45:33+11:00","code":{"coding":[{"system":"http://loinc.org","code":"58410-2","display":"Complete blood count (hemogram) panel - Blood by Automated count"}]}},{"resourceType":"Claim","id":"Claim100150","identifier":[{"system":"http://happyvalley.com/claim","value":"12345"}],"status":"active","patient":{"reference":"Patient/1053"},"created":"2014-08-16","provider":{"reference":"Organization/999"},"use":"claim","diagnosis":[{"sequence":1,"diagnosisCodeableConcept":{"coding":[{"code":"E11.9","system":"http://hl7.org/fhir/sid/icd-10-cm","display":"Type 2 diabetes mellitus without complications"}]}}]},{"resourceType":"Basic","id":"Basic10","code":{"coding":[{"extension":[{"url":" https://fhir.athena.io/StructureDefinition/ah-evidence-type","valueString":"NOTES"}],"display":"CMS accepted for HCC 9: Lung and Other Severe Cancers on 2020-01"}]}},{"resourceType":"Basic","id":"Basic11","code":{"coding":[{"extension":[{"url":"https://fhir.athena.io/StructureDefinition/ah-evidence-type","valueString":"SPC"},{"url":"https://fhir.athena.io/StructureDefinition/ah-evidence-claim-date","valueDate":"2020-09-29"},{"url":"https://fhir.athena.io/StructureDefinition/ah-evidence-provider-name","valueString":"MORGINSTIN MARK S DO "},{"url":" https://fhir.athena.io/StructureDefinition/ah-evidence-organisation-name","valueString":"GET WELL PHC"},{"url":"https://fhir.athena.io/StructureDefinition/ah-evidence-provider-contact-number","valueString":"123-120-1223"}],"code":"92","display":"Radiation oncology"}]}}]},"request":{"method":"POST"}}]’
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Add risk adjustment gaps to patient chart

POST
/v1/{practiceid}/riskgaps/condition
BETA: Records a risk adjustment gaps in the patient's risk tab
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Input Parameters

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required

practiceid integer practiceid
Content-Type string Content type of the payload

Request Body

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Output Parameters

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entry array
resourcetype string Bundle
type string Batch-response
Example Code