The ABC's of HCC's

ABC'S OF.pngWith 60% of the Merit-Based Incentive System (MIPS) score for providers coming from risk adjusted quality and resource use scores, it is critically important to accurately reflect the acuity of your patient population. Doing so will allow your quality and cost scores to accurately reflect the care provided by your physicians.

Now that diagnosis coding is much more critical, both for immediate fee-for-service reimbursement and over the course of 2017 as Medicare uses that diagnosis data for Risk Adjustment under MIPS. So, do you know the ABC's of HCC's? Here are some key factoids I thought I would share with you.

  • HCC's are based on diagnosis only.
  • Only a subgroup of diagnosis codes group to an HCC.
  • A patient may have several HCC's per encounter.
  • Co-existing conditions are as important as the principal or primary diagnosis
  • Not all Medical Records are created equal - a diagnosis may be documented in one record in the past history and would affect patient care, yet in another medical record would not affect patient care and is not not coded.
  • Considerations to take into account when reviewing HCC records to assign codes for co-existing conditions include specialty of physician – orth vs. cardio; type of visit – ER, H/P etc; Handwritten, dictated, EMR and presenting problem/focus of treatment.
  • The difference in the type of doctor makes HCC Coding variable. Primary care doctors assess all aspects of patient health, how various organ system and co-existing condition inter relate and affect the patient as a whole, where specialists generally assess problems specific to their specialty, but must take into consideration co-existing conditions that affect their decision making and treatment.
  • All medications and potential interactions must be assessed at every visit by the physician.
  • The entire note becomes relevant to HCC coding.
  • HCCs are chronic conditions that statistically have shown to utilize more resources for a given diagnosis.
  • Chronic diseases that have potential for exacerbation's should be reported e.g. COPD, DM, CHF.
  • Not all chronic conditions are HCCs.
  • Not all HCC's are chronic conditions e.g. sepsis, aspiration pneumonia, acute pancreatitis.
  • HCC's allow payment risk adjustment for severity of illness/co-existing chronic diseases.
  • Payment for multiple chronic conditions is additive.
  • Multiple HCC's affect decision making, treatment, resource allocation and morbidity and mortality.
  • Code all HCC relevant to the patient care for a given encounter
  • It is important to learn importance of co-existing conditions under the HCC model and learn to interpret relevant data charted in progress notes by physicians.
  • Supporting Documentation - all conditions documented within the progress note (this includes the chief complaint, history of present illness, ROS, PE, problem list, assessment/plan) are acceptable for coding IF they are supported.
  • Supporting documentation comes in various ways depending on how the encounter is documented by the provider.
  • MEAT – Monitor, Evaluate, Assess or Treat the conditions that have been documented.
  • TAMPER – was created to assist coders when faced with diagnosis listed as PMH or Medical History, as a way to help determine if those diagnosis should or shouldn’t be submitted. TAMPER – treatment, assessment, monitor/medicate, Plan Evaluate. This refers to the CMS guidance for valid risk adjustment coding.

I hope these were helpful. How is your facility addressing this critical area? Please share your thoughts and comments!