HCCs bring new challenges, may offer outpatient CDI opportunities
November 13, 2014
CDI Blog - Volume 7, Issue 27
Inpatient coders are familiar with risk-adjusted methodologies—where a combination of diagnoses lead to higher-weighted code groupings--but many outpatient coders may not have encountered them.
That's likely to change as hierarchical condition category (HCCs) coding become more prevalent, due to the rapid growth of Medicare Advantage (MA) plans. Medicare is separated into four parts:
- Part A, typically used for inpatient hospital insurance
- Part B, used for physician services and outpatient hospital care
- Part C, used for MA plans, introduced in 2004 and combines Part A and B services, and sometimes Part D, or pharmacy benefits
Approximately 14.4 million people, or 28% of Medicare beneficiaries, are enrolled in MA plans. This is up nearly 10% since 2012. One reason for the growth in MA enrollees is that accountable care organizations use HCCs as a component of their payment model, according to Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA, AHIMA-approved ICD-10 CM/PCS trainer. King is a senior HIM consultant for Nuance Communications in Dunwoody, Georgia.
Each MA patient is assigned a risk-adjustment factor (RAF) score, according to King. Organizations are given an average RAF score where 1 represents a typical patient. A score less than 1 means a healthier patient and a score higher than 1 indicates a patient likely to require greater resources for treatment.
Similar to complication or comorbidities (CC) and major complication or comorbidities (MCC) on the inpatient side, certain diagnoses or statuses will increase a patient's RAF, King says.
MA plans use the RAF to predict a patient's care in the following year, but providers must document diagnoses tied to HCCs each calendar year so the diagnoses can be included in the calculation.
The HCC model categorizes diagnosis codes into disease groups that are similar both clinically and financially, based on CMS' analysis of clinical information and cost data. HCC create a hierarchy so that patients are coded for the most severe manifestation among related diseases, such as diabetes.
For unrelated diseases, HCCs accumulate. For example, the diagnoses for a male patient with heart disease, stroke, and cancer will map to at least three separate HCCs, and his predicted cost of treatment will reflect increments for all three problems.
CMS publishes the data for which diagnoses map to HCCs and what their weights are and updates them annually.
Documentation requirements for HCCs
Coders will have to pay close attention to the source and type of diagnoses to map them to HCCs. HIM directors or office managers should identify MA beneficiaries so coders are aware of which patients' documentation will require this additional scrutiny, according to King.
"CMS actually specifies which providers the diagnoses can be taken from in the documentation to assign the codes," King says. Those providers are:
- MD
- Doctor of optometry
- Doctor of chiropractic
- Doctor of dental surgery
- Doctor of osteopathy
- Doctor of podiatry
- Nurse practitioners, certified nurse specialists, and physician’s assistants
- Therapists, except respiratory therapists
- Licensed clinical social worker/clinical social worker
- Certified wound care/ostomy nurse
"Not all diagnoses are counted as HCCs, and I think [CMS] did a really good job [identifying] which diagnoses are going to be impacted," King says. "They're high cost and patients are likely to have problems with these conditions the following year."
Generally, those diagnoses can be separated into three groups, according to King:
- High-cost medical conditions, such as current cancers, heart disease, or hip fractures
- Acute and chronic conditions, status codes, etiologies, and manifestations, such as chronic obstructive pulmonary disease (COPD) and diabetic neuropathy
- Common, rare, congenital, acquired, non-curable or conditions that can be cured, so long as they are current and impact the encounter by requiring either monitoring, evaluation, assessment, or treatment (MEAT)
Since that last group can consist of so many conditions, King recommends coders remember the acronym MEAT when looking at documentation for conditions that can be HCCs.
Diagnoses are excluded from mapping to HCCs when they:
- Do not predict future cost, such as appendicitis
- Have a high degree of discretion or variability in diagnosis or treatment, such as symptoms and osteoarthritis
"You may think appendicitis is a big deal, but for a person who has appendicitis, that's probably not going to impact [his or her] care in the next year," King says.
Additionally, diagnosis codes from labs, radiology, and home health claims are typically not captured for HCCs because they are not reliable and may indicate ruled-out diagnoses, according to King.
"In particular, I see a lot of HCC diagnoses coming from radiology [when reviewing claims], but they cannot be captured unless the provider, the attending physician, really reiterates them and takes them into consideration when treating the patient," she says.
HCC documentation challenges
Accurate diagnosis coding is the biggest challenge for properly mapping to HCCs due to problems with provider documentation, according to Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, AHIMA-approved ICD-10-CM/PCS trainer, senior director of HIM innovation for Nuance Communications in Atlanta.
Coders might think that the top concern for documentation with HCCs might be related to clinical information, but that's often not the case.
"When auditors come in and review HCC claims, their number one problem is legibility," King says.
Beyond that, HCCs have other specific requirements coders will have to ensure are on all claims, including:
- Two patient identifiers on each page of the medical record, such as the patient's name and birthdate
- A complete and legible date of service
- Legible documentation, provider signature with credentials and date
In addition, it must be a face-to-face encounter with one of the provider types listed above in the correct setting.
"It can't be a telephone call," King says.
Coders should not report conditions from documentation that is cloned or copied and pasted.
"Any historical condition must be reiterated," King says, such as a patient with an acute myocardial
infarction.
Conditions cannot be assumed. For example, if a provider renews a prescription for needles and testing strips, a coder cannot report diabetes unless additional documentation supports that diagnosis.
Diagnostic tests must also be reiterated and not copied, with the significance noted by the provider, King says.
Clinical concerns still exist for proper HCC capture, especially regarding specificity for mapping to the highest-weighted HCC, according to King.
For example, if a provider simply documents "diabetes mellitus," coders would report ICD-9-CM code 250.00 (type 2 diabetes mellitus without complications). This maps to HCC 19, which has a weight of .118. Many providers will document this because they are not aware of the specific terms in ICD-9-CM necessary to assign more specific diabetes codes.
However, if they document "type 2 diabetes with renal manifestations," coders can assign code 250.40 (diabetes with renal manifestations, type 2 or unspecified type, not stated as uncontrolled). This maps to HCC category 18, with a weight of .368.
Providers will need to be more specific with diagnoses such as diabetes and arrhythmias. They will also need to note chronic conditions and manifestation in order for coders to assign the most appropriate diagnosis codes that map to HCCs.
Coders who work for the insurance carriers providing MA plans will sometimes work with coders in provider offices in order to ensure documentation is complete, Cassidy says. Organizations must assess their methods for education, monitoring, and coding specifically for HCCs to mitigate compliance risks, she adds.
Email your questions to editor Steven Andrews at sandrews@hcpro.com. Information for this article came from the HCPro webcast “HCC Documentation and Coding Tips for Physician Practices and Outpatient Departments.”