Symposium spotlight: Take the HCC plunge with Pinson

Editor’s note: Richard Pinson, MD, FACP, CCS, will present “A Deep Dive into HCCs” on Day 1 of the ACDIS Symposium: Outpatient CDI, which takes place November 14-15 at the Hyatt Regency in Austin, Texas. Pinson is the principal and medical director at Pinson and Tang LLC and the best-selling co-author of the CDI Pocket Guide, the Outpatient CDI Pocket Guide: Focusing on HCCs, and the Pocket Guide for Coding Professionals.

ACDIS Blog: In your opinion, what’s the biggest misconception about Hierarchical Condition Categories (HCC)?
Pinson: I believe the biggest misconception about HCCs may be that the risk adjustment factor (RAF) score derived from HCCs affects the revenue to physicians or hospitals from Medicare Advantage Plans (MAP). Only the MAP benefits from improved RAF scores and they are prohibited from passing its savings on to providers. Providers in an Accountable Care Organization (ACO) and other Affordable Care Act (ACA) shared-risk programs, however, do benefit because they are paid directly by CMS subject to RAF adjustment.

ACDIS Blog: How does HCC capture effect reimbursement and quality measures?
Pinson: Capturing more HCCs adds up to an increase in the RAF which is then used to adjust payment for MAPs, ACOs, and certain other risk-share programs. Higher RAF equals higher reimbursement.

The RAF is also used to severity adjust CMS pay-for-performance metrics that affect hospital revenue and physician pay-for-performance metrics which, in turn, affect their physician fee schedule. Higher RAF equals greater baseline severity of illness which results in better performance metrics.

Other governmental and private sector organizations (e.g., Medicaid, commercial payers, Healthgrades) also use RAF adjustment to measure and report quality/performance of hospitals and physicians.

ACDIS Blog: Why, in your opinion, should CDI programs expand to HCC reviews? Is it just an outpatient concern?
Pinson: The primary care provider’s office, where every one of a patient’s problems should be evaluated every year, is most productive for capturing HCCs and expanding CDI activities. A diagnosis only needs to be captured once in a calendar year on claims.

During hospitalization, nobody knows which diagnoses have already been captured, so searching and querying for them during hospitalization may be a futile effort. On the other hand, documented chronic diagnoses can be freely captured and coded on inpatient claims, so it’s essential that the inpatient CDI team recognize important HCCs, making sure they get coded.

Finally, from a practical standpoint, the emergency department is not a productive setting for capturing HCCs. Trying to address the details of stable chronic conditions interferes with efficient ED operations and patient flow, and it has the same limitation of not knowing what’s already been captured during the year. It’s much better to focus CDI resources in the ED on the documentation of important diagnoses at the time of admission for those patients being admitted that can affect DRG assignment.

ACDIS Blog: How can CDI professionals educate physicians about HCC capture? What’s your best advice for getting physician buy-in for these reviews?
Pinson: Physician education has always been a problem unless the doctors are seriously and personally interested or unless they are held accountable in some way. Sometimes, they will be influenced by the quality/performance effect, especially if their performance is known to be suboptimal.

Physicians’ fee schedules may be affected by poor pay-for-performance metrics even though there is no extra income from MAPs for RAF improvement. The income of providers participating in ACOs and certain other ACA shared-risk programs is affected by RAF scores and they should be interested in HCCs.

The best approach is focusing on physician office practices with one-on-one education supported by the practice’s leadership. Hospitalists should also be held accountable for HCC education by their leadership and hospital executives.

ACDIS Blog: How have you seen the CDI industry change and expand over the last 10-plus years? How do HCC reviews fit into that changing landscape?
Pinson: While some CDI efforts started in 1983 with the implementation of DRGs having CCs only and grew from there, the implementation of MS-DRGs with the CC/MCC distinction in 2007 really accelerated the importance and growth of CDI, prompting the establishment of ACDIS in 2007.

The rise of HCC payment and performance adjustment has recently generated interest in improving RAF scores. CDI programs, already prevalent, were the logical place to turn driving further CDI growth. As payment based on performance grows, these trends will intensify.

ACDIS Blog: If you could live anywhere in the world, where would it be and why?
Pinson: I’m living there now—right here in Chattanooga. It offers the best of everything I could want every day, not far from kids and grandkids. My wife Amanda and I wouldn’t mind being able to spend a few months every year on an Aegean or Caribbean island, in Tuscany or Santa Barbara, California—but that’s an unlikely scenario.