Beyond outpatient: CMS-HCC version 23 released

Like all reporting structures, CMS updates its Hierarchical Condition Category (HCC) list each year. Recently, version 23 was released, and it contains some notable additions that CDI professionals—whether inpatient or outpatient—should be aware of.

The HCC model is a risk-adjustment methodology used for Medicare Advantage, population benchmarking for Accountable Care Organizations, and quality programs. In some cases, conditions that qualify for an HCC also count as CCs/MCCs in the MS-DRG system.

With version 23, CMS added several categories in the mental health area and one to the chronic kidney disease (CKD) grouping. While mental health may not be a common review focus for CDI professionals, capturing those conditions is paramount for accurate reporting and reimbursement. (See p. 13 for a list of the additions.)

“If you don’t know the level of specificity for code assignment, then you could be affected financially and/or with meeting quality measures,” says Tammy Combs, RN, MSN, CCS, CCDS, CDIP, director of HIM practice excellence and CDI/nurse planner for AHIMA. Denials management may also be affected, she says. “Anytime you have codes assigned, they need to be supported by the documentation.”

Mental health and substance use additions
With an increased focus on population health, it’s not surprising to see mental health issues added, according to Sonia Trepina, MPA, director or ambulatory CDI services for Enjoin CDI in Collierville, TN.

“I was excited to see the additions under the mental health and substance abuse categories because we know that those conditions take time, resources, and money to care for. Population health is such an important development in our industry, and I think this recognizes that evolution,” she says. “Capturing these codes will give us the data we need to determine what industry improvements and changes are needed to care for patients with these conditions.”

The additions to the mental health category allow for great specificity when it comes to the type and nature of the mental health or substance use condition. Adding this specificity, Combs says, will help the healthcare industry better care for these patients since “we’ll have a better read on the actual numbers behind these conditions. Various research and treatments are being planned and evolved, all based on the documentation. That’s where my initial thought goes. It’s all about identifying those conditions.”

Of course, CDI professionals will likely need to provide education to the medical staff surrounding these changes.

“The language that the providers use isn’t necessarily the language that will trigger an HCC,” says Brett Senor, MD, CRC, CCDS, physician associate for Enjoin. “If you asked me whether ‘major depressive disorder’ was enough and I didn’t know better, I would think it was.”

Education has to begin with the CDI professionals themselves, though, says Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, former national director of coding, quality, education, systems, and support for a national healthcare delivery system (now retired).

“This may be an area some of the CDI specialists haven’t been exposed to because it’s mental health, not physical health, so they may need to read up on those conditions,” she says. “Maybe reach out to someone in the mental health department, the ED physicians, and then the hospitalists. There are mental health workers who aren’t physicians, too. They would be another good group to talk with now.”

Once the CDI staff has done their research, they’ll be able to present a united front to the physicians and ensure they’re passing along accurate information. During reviews, Bryant suggests keeping an eye out for psych assessments and consults. “We may need to query for some of these mental health conditions now,” she says. In the short term, the new mental health categories will likely add some work for CDI professionals in regard to self-education, physician education, and review time.

However, in the long term, the new categories will give the industry more data surrounding mental health concerns and help shape better treatments and guidelines, says Senor—which speaks to the larger population health mission of CDI.

“By expanding the number of diagnoses, it really expands the awareness of psychiatric disorders,” he says.

CKD stage III
Though HCCs existed for the other stages of CKD in previous versions, version 23 was the first to add a category for CKD stage III. While this is a relatively small change in comparison to the multiple changes in the mental health category, it validates CDI specialists’ pursuit of CKD staging, Combs says.

“I think it’s something we’ve always been looking for, so it solidifies the need to look for that,” she says.

Before this addition, CKD stage III could be captured in the MS-DRG system, but it didn’t have a corresponding HCC. According to Senor, the addition allows for better reporting of a very common type of CKD.

“CKD stage III, in my experience, is the most common stage of CKD, but it wasn’t risk-adjusted before. You can also capture it even on the inpatient side with the interactions with the CKD too, which means it’s more than an outpatient issue,” like with hypertensive heart disease, he says.

The new CKD category could also make a big financial difference for hospitals, according to Trepina.

“We see a lot of CKD stage III treated, and if you add that count up, you’re definitely looking at some dollar impact that’s been missing,” she says.

Inpatient concerns
While the most common location for capturing HCCs is in an outpatient setting (for example, at the patient’s primary care office) because of the often chronic nature of the conditions, they don’t have to be captured in that setting.

“You think HCCs and you think outpatient, but with CDI professionals, they need to be thinking of the continuum of care,” says Combs. “Instead of just focusing on what needs to be documented on the inpatient side, let’s look for high-quality documentation.”

Plus, there’s actually a fair bit of overlap between the conditions traditionally focused on by inpatient CDI professionals and those under the purview of outpatient CDI professionals, Senor says.

“I would probably encourage inpatient CDI specialists to be aware of where there is overlap between HCCs and CC/MCCs,” he says. “You don’t want query fatigue, so you need to know where the impact is.”

Before diving into HCC reviews, Trepina echoes Senor’s advice to find where you’ll have the most effect.

“Start with chart reviews,” she says. “From there, depending on the results, you can start with the physician education and some level of querying.”

Though HCCs may be outside your usual realm of review focus areas if you work on the inpatient side of things, Combs says to keep the focus on documentation quality at the forefront of your reviews.

Understanding the coding guidelines and updates to ensure documentation correctly translates to codes is helpful and sometimes necessary, but don’t underestimate the effect of good documentation.

“When you really get in there and think about the effect of high-quality documentation,” Combs says, “you just keep finding places that it’s impacting.”