HCC Coding and Documentation - Partnering with Providers
As coders we realize the importance of assigning the most specific diagnosis codes supported by provider documentation. Providers, unfortunately, do not always document as thoroughly as they should. How do we help our providers improve their documentation skills?
Let’s Talk
What do you already have in place for communication tools? Ideas include office lunch-and-learns, quality committees, care management/coordination meetings, staff meetings, etc. These types of gatherings are perfect for sharing HCC information with providers. Start slowly, then progress by sharing documentation do’s and don’ts. In my experience, nothing works better than showing a provider how a few quick changes in their documentation habits can create a clearer picture of their patients’ overall health, support medical decision making, and improve the accuracy of HCC assignment and, ultimately, patient risk adjustment scores.
Bullet Points
Providers need some key information about HCC documentation and coding. For example:
The Hierarchical Condition Categories system is the CMS risk adjustment process that pays Medicare Advantage plans based on the health status of their members.
Medicaid and many commercial payers have their own HCC process in place.
About 8% of ICD-10 diagnosis codes map to 83 HCC codes. HCC codes add up to a Risk Adjustment Factor (RAF) assigned to each patient for one year.
The HCC model is made up of ICD-10 diagnosis codes that represent costly, chronic diseases like diabetes, CKD, COPD, CHF, obesity, seizure disorders and cancers.
The HCC system creates a hierarchy so that patients’ conditions are coded to the most severe manifestation among related diseases.
Some diagnoses reported together – such as congestive heart failure and diabetes – generate a higher Risk Adjustment Factor (RAF) resulting in higher payments. RAF’s are higher for patients with greater disease burden, lower for healthier patients.
Demographic data and diagnosis codes reported on your claims determine a patient’s HCC assignment and risk score.
Each January 1, the RA slate is wiped clean. Chronic conditions must be reported at least once per year.
Baby Steps
Once providers understand HCC basics, determine what conditions your practice sees most often. Then ask providers to focus on those conditions first. You might want to start with the 10 most common HCC’s:
Diabetes without complications – HCC 19
Breast, prostate, and other cancers – HCC 12
Diabetes with chronic complications – HCC 18
Seizure disorders and convulsions – HCC 79
Specified heart arrhythmias – HCC 96
Congestive heart failure – HCC 85
Other significant endocrine and metabolic disorders – HCC 23
Chronic obstructive pulmonary disease – HCC 111
Major depressive, bipolar, and paranoid disorders – HCC 59
Morbid obesity – HCC 22
NOW WHAT?
With your eyes on the prize, audit charts to identify unreported conditions. Discuss findings with providers and present concrete examples for them. Here is an eye-opening “before and after” snapshot that shows how important documentation specificity is:
SUMMARY
Over the past two months we have seen that the HCC payment system requires changes to the way we document and code chronic conditions. Working together with your providers is the most effective way to get the job done. Your success translates into a more complete picture of your patients’ health status, resulting in more appropriate reimbursement for complex patient populations. And finally, by appropriately documenting and reporting the complexity of your patients, your practice is eligible for greater CMS revenue that can then be reinvested to better meet the needs of patient care.
To view and download the complete HCC table with linked diagnoses, click here:
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/Risk2020