The Centers for Medicare & Medicaid Services (CMS) has implemented a key update as part of the May 2025 payment cycle: a Risk Adjustment Reconciliation Rerun for Payment Year (PY) 2015. This change involves the reinstatement of the 2012 CPT/HCPCS exclusion list used to filter Fee-For-Service (FFS) diagnoses, with implications for Medicare Advantage Organizations (MAOs) across the board.
Let’s walk through what this means, why it matters, and how to ensure your organization stays aligned with this update.
What Is the 2015 Risk Adjustment Reconciliation Rerun?
The May 2025 CMS payment adjustments include a rerun of the PY 2015 risk adjustment reconciliation. While 2014 is the service year tied to PY 2015 payments, CMS has chosen to reinstate the 2012 CPT/HCPCS list—not the 2014 list—as the filtering mechanism for identifying which FFS diagnoses are excluded from risk score calculations.
Why 2012 Instead of 2014?
This decision stems from the fact that the reopening of the 2015 Part D payment reconciliation was based on systems and methodologies in place at that time, which included the 2012 list. CMS is maintaining consistency by reverting to that list for this specific rerun.
What Is the CPT/HCPCS Exclusion List?
The Outpatient CPT/HCPCS Excluded Services List is used to filter out certain diagnosis codes based on whether they were supported by CPT/HCPCS procedure codes during the service year. This ensures only valid, supported diagnoses are considered in risk score calculations.
For the 2015 rerun, CMS applied the 2012 version of this list—even though the reconciliation impacts 2014 service year data—because that was the list applicable when the original reconciliation was re-opened.
Where Can You Find the Updated List?
CMS has made the applicable exclusion list available on the CSSC Operations website, listed as:
Outpatient CPT HCPCS Excluded Services List for PYs 2013–2017
Stakeholders should refer to this specific document to determine which codes were filtered in the updated reconciliation rerun.
Referenced CMS Communication
For additional clarification, MAOs and Part D sponsors are encouraged to consult the Medicare Advantage/Prescription Drug System (MARx) August 2024 Payment Memo, originally published on July 31, 2024. This memo provides context on:
Years affected by the CPT/HCPCS list reinstatement
Rationale behind the use of the 2012 list
Additional instructions for impacted organizations
Why This Matters to MAOs
This update may affect final reconciled risk scores for PY 2015 and could result in revenue adjustments for certain Medicare Advantage plans.
Key Implications:
Revenue Impact – Payments for PY 2015 may change depending on how diagnoses were previously filtered.
Audit Preparedness – Historical encounter and FFS data may need to be re-evaluated for compliance and accuracy.
Operational Review – Compliance teams should ensure that their documentation aligns with the CPT/HCPCS list applied during this rerun.
What Should You Do Next?
To stay aligned with CMS guidance and prepare for any downstream impacts:
Action Steps for MAOs:
Download and Review the 2012 CPT/HCPCS Exclusion List
Available on the CSSC Operations site under the PYs 2013–2017 exclusion list.Assess Internal Reconciliation Data
Ensure that your diagnosis data from PY 2015 aligns with the criteria from the reinstated list.Update Risk Score Projections
Adjust any internal models or forecasts that rely on previously calculated risk scores from PY 2015.Communicate with Finance and Compliance Teams
Inform relevant departments about the potential financial and reporting impacts.Monitor CMS Announcements
Continue to track updates from CMS or HPMS that may impact historical payments or methodologies.
Frequently Asked Questions (FAQs)
Q: Why is CMS using the 2012 CPT/HCPCS list instead of the 2014 list for PY 2015?
A: Because the reopening of the 2015 reconciliation used systems from that period, CMS reinstated the 2012 list to maintain consistency.
Q: Where can I find the applicable CPT/HCPCS exclusion list?
A: The list is posted on the CSSC Operations website under “Outpatient CPT HCPCS Excluded Services List for PYs 2013–2017.”
Q: Will this impact current or future payments?
A: Yes, this rerun has already been applied to the May 2025 payment and could result in revenue changes for affected plans.
Q: Does this apply to all Medicare Advantage Organizations?
A: It applies to any MAO that submitted encounter data relevant to PY 2015 and may have had risk scores affected by the change.
Final Thoughts
The reinstatement of the 2012 CPT/HCPCS exclusion list for the 2015 risk adjustment reconciliation underscores the importance of staying vigilant about CMS retroactive changes. Medicare Advantage Organizations should act swiftly to assess how this update affects historical data, payments, and compliance metrics.
If you’re unsure how your plan is impacted, now is the time to coordinate with compliance, finance, and risk adjustment teams to ensure a full understanding of the update.