hcc & risk assessment coding - medical advantage group · pdf filedisclaimer medical...

HCC & Risk Assessment Coding

Candace Lewis, MBA, CPC – Director of Revenue Cycle Management

May 17, 2017

Disclaimer

Medical Advantage Group would like to disclose that no one

in a position to control or influence the content of this activity

has reported relevant financial relationships with

commercial interests.

The information and guidelines contained in this activity are

generalized and may not apply to all practice situations.

Medical Advantage Group recommends that legal advice be

obtained from a qualified attorney for specific application to

your practice. The information is intended for educational

purposes and should be used as a reference guide only.

2Value Driven. Health Care. Solutions.

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ValueDriven.HealthCare. Solutions.Value Driven. Health Care. Solutions.

Agenda

» Introduction to HCC & Risk

Adjustment

»FFS Coding vs. HCC Coding

»Coding Rules

»Common Errors

HCC & RISK ADJUSTMENT INTRODUCTION

Value Driven. Health Care. Solutions. 5

What is Risk Assessment?

A process for health

insurance plans, such as

Medicare Advantage

plans and ACA plans, to

be compensated based

on underlying health

conditions of enrollees


Payment is

adjusted due to

– Patient age

– Disability

– Financial status

– And diagnoses

What is HCC?

Hierarchal Condition Categories

– Sorting mechanism for chronic conditions that assigns a

payment value on care of a patient with that condition

RxHCC

– Separate consideration of prescription costs for a patient

with that specific condition. This may be more or less

than the HCC, and some conditions like HTN have an

RxHCC, but no HCC.


Types of Risk Adjustment Plans


Medicare Advantage plans

CDPS

Private Risk Pools (created under ACA)

– All premiums go into a pool and are redistributed based

on the patient population risk score

How Does It Work?

Insurance company

pays the physician for

services performed


If chronic conditions

are properly

documented and

coded CMS pays the

insurance company

extra for the patient

based on the patient’s

risk adjustment score

How Does It Work?

Each diagnosis that is costly to manage is assigned an

HCC


How Does It Work?

Each HCC is assigned a risk adjustment factor score


How Does This Relate to CPC+ ?

CPC+ patients

receive a risk

adjusted

monthly care

management

fee


CMS assigns

beneficiaries to

a risk tier

based on the

individual’s

HCC score

Scores are

generated for

all beneficiaries

and updated

yearly

How Does This Relate to CPC+

Beneficiary scores will determine which risk quartile the

beneficiary will be assigned


FFS CODING VS. HCC CODING


Shift in Focus

Most coding is done for medical necessity of the visit

HCC coding requires a wider focus, reporting any

chronic conditions that are documented and have an

effect on the care.


Similarities

Code to the

highest level of

specificity


Each individual

encounter must

be able to stand

on it’s own.

Review coding

guidelines on a

regular basis to

ensure guidelines

are being followed

Differences

Each chronic condition

needs to be reported

once a year or the payers

will miss out on additional

risk adjustment

reimbursement

In FFS reporting medical

necessity is required. In

HCC coding MEAT is

required.


Most Common HCC Diagnoses

Diabetes mellitus

Cancer

Heart arrhythmias

Ischemic heart disease

COPD

Congestive heart failure

Vascular disease

Angina

Stroke

Rheumatoid Arthritis


CODING RULES


Do Your Diagnoses Have MEAT?

Code ALL diagnoses that have MEAT…


Measured

signs,

symptoms,

progression /

regression

Evaluated

test results,

response to

treatment

Addressed

order tests,

referrals, review

records

Treated

scripts,

therapies

Do Your Diagnoses Have MEAT?

MEAT must be specific and have a direct link between

the disease and the MEAT

MEAT can be negative results or findings

MEAT must be documented in the same date of service

MEAT can be in any part of the progress note


Causal Relationships

Proper documentation is imperative of

causal relationships

– Diabetic Nephropathy

– Diabetes and Nephropathy

HCC payments are greatly affected by the

relationship and there are costly penalties

to the payers if this is coded incorrectly

– Penalties apply whether upcoded or

downcoded


COMMON ERRORS


Common Errors

Disappearing Diagnoses

– Patient was documented

as morbidly obese in

2015. Patient is still

morbidly obese, and

provider has even

discussed weight loss

with the patient.

However, only the BMI

was reported.

Popular Offenders:

• Morbid Obesity

• Lower extremity amputation

status

• Ostomy status

• Transplant status

• Down syndrome

• HIV status

• Self-harm; Suicidal ideation


Common Errors

Use the most specific code possible

ICD-10 Code ICD-10 DescriptionHCC

Group

Risk Adjusted

Factor

F329Major depressive disorder,

single episode, unspecified 0 0.00

F320Major depressive disorder,

single episode, mild58 0.395


Common Errors

Missed diagnosis

– Look for diagnosis to be documented elsewhere in the

record


Common Errors

Not documenting due to

– Neuropathy due to

– Diabetes

– Alcoholism

– Documentation including “due to” will support the causal

relationship, allowing for proper reporting of diagnoses

History Of

– Only use history of for a condition that has been

completely resolved

– Coders can not code for a condition documented as

“history of”


Common Errors

Documentation of med list review

– Including indication that the patient med list was reviewed

on this date will add MEAT to your progress note for

chronic conditions

Avoid ambiguity

– Coders can not make clinical decisions, make

assumptions or fill in the blanks

– If it isn’t written down, the coder can not code it

Document with words, not codes

– Per CMS guidelines codes are not documentation, must

use words for diagnoses and documentation


QUESTIONS


Medical Advantage Group’s CPC+ Solution

CPC+ Solution Overview


Medical Advantage Group

Industry leading practice transformation company

20 years of experience helping practices succeed in

value-based contracts

Transformed more than 1,000 primary care practices in

Michigan and Ohio

Key partner in building one of

the largest PCMH networks in the U.S.

Key partner in the Great

Lakes Practice Transformation

Network, helping Ohio

practices prepare for MACRA


For More Information


https://www.medadvgrp.com/cpcplus

Value Driven. Health Care. Solutions.

Sherri Kent (Ohio)517-999-8017 • [email protected]

Jeff McKay (Michigan)517-999-8005 • [email protected]

CANDACE LEWIS, MBA, CPCDIRECTOR, REVENUE CYCLE MANAGEMENT

[email protected]

WORK: 517-219-9600


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