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HCC CODING LORI LAUBACH, CHC
PRINCIPAL
MOSS ADAMS LLP
JUDY PRIVETTE, RHIT, CCS-P
SENIOR LEARNING CONSULTANT
THE PERMANENTE MEDICAL
GROUP
AHIA 33rd Annual Conference – September 21-24, 2014 – Austin, Texas
www.ahia.org
1
Today’s Topics
What is HCC?
Risks
Data Mining
Audit Approach
What is HCC Coding?
Hierarchical Condition Category (HCC) payment model
Risk adjustment payment system
HCC Model relies on diagnosis coding (ICD-9CM) submitted to allocate funds
CMS implemented in 2004 as a methodology for paying Medicare Advantage plans
CMS Audits
Risk Adjustment Data Validation (RADV) audits
Requires the supply of the “one best record” reflecting the HCC conditions reported and paid
What is an HCC? 4
70 HCC categories
An HCC category is correlated to ICD-9 Diagnosis
codes
Example:
ICD-9 Diagnosis Description HCC
Code
250.00 Diabetes without complications 19
496 Chronic Obstructive Pulmonary Disease 108
174.9 Breast Cancer 10
HCC and ICD-9 Code Mapping
ICD-9 Code ICD-9 Description HCC Model Category
260 Kwashiorkor
21 262 Nutritional Marasmus
2630 Sever malnutrition
2632 Arrest Devel D/T Level
4560 Esophag Varieces w/ bleed
25 4561 Esophag Varieces w/o bleed
45620 Bleed esophageal
45621 Esoph Varice NOS
5712 Alcohol Cirrhosis
26 5713 Alcohol Liver Dz
5715 Cirrohosis of Liver NOS
5716 Billary Cirrhosis
HCC Payment Model
Why do payors care?
Patient Any type of
Visit
Diagnosis Codes
Submitted
Carrier translates to HCC Codes
CMS funds Carrier for next year
Ties to quality measures
and patient outcomes
Provider documentation
drives code selection
Annual Process
Medicare Risk Adjustment Plans
Payment is made to Medicare Advantage Health
Plans – not the individual provider
Payment is per HCC category- not the Diagnosis
code
HCC’s must be captured every 12 months
Payment is made once per DX code, regardless of
how many times it is reported during the 12 month
period
Characteristics of CMS-HCC Model
Risk Scores are Critically Important
Two Pronged Impetus:
Support the accurate representation of patients’ illness
which will inform risk-adjusted Morbidity and Mortality
data.
Ensure claims information represents both the illness of
the patients as well as provides opportunity for
appropriate compensation.
Contracting Impacts
Commercial insurance gain-sharing contracts are
becoming more common and are risk-adjusted.
For Medicare Advantage contracts, payors receive
a risk-adjusted PMPM. Enrollment is continuing to
grow.
All Exchange products will be impacted by risk
scores.
Upside to Risk Contracts
(Shared Savings)
Payors encourage providers to code for all clinical
issues a patient may have as it drives the expected
“allowed” claims cost.
The expected “allowed” claims cost is determined
by multiplying a patient’s risk score by the average
cost of an insured member.
A portion of reimbursement is impacted by
comparing a provider’s expected “allowed” claims
cost to the actual incurred “allowed” cost.
Documenting Chronic Conditions
A provider must see the patient at least once a year
for compliance with the MA Plan.
Must be face to face visit
Documentation must indicate managing all chronic
conditions
Documenting Chronic Conditions, cont
CMS is looking for key elements :
Assessment Plan
Improved D/C Meds
Example: DM, stable well controlled, continue meds
Deteriorating- Refer to Specialist
Support all diagnosis documented
Assessment and/or Treatment
Documenting Chronic Conditions, cont
History Of
History of means the patient no longer has the condition
Frequent documentation errors regarding use of history of:
Coding a past condition as active
Coding history of when condition is still active
Exception: It is appropriate to document/code “history of” when documenting some status conditions (e.g. Amputation).
Examples:
Documenting Chronic Conditions, cont
Additional Coding Guidelines:
Face to face visit
Documentation must show how chronic condition is being treated, managed or assessed
Each diagnosis must have an assessment and a plan
Additional Coding Guidelines
Providers must report all diagnoses (not just primary
diagnosis) that impact the patient’s evaluation, care,
and treatment including:
Main reason for visit
Co-existing acute conditions
Chronic conditions (such as A Fib, CHF, CKD, RA, DM,
COPD/Asthma, Cardiomyopathy)
Care rendered
Conclusion and diagnosis
Commonly Miscoded HCC groups
When a member presents with DM2, more often than not,
most providers and coding/billing staff miss the HCC
opportunity because they forget to properly document:
manifestations
complications
DM with a manifestation requires that you document and
code the two or more codes to reflect the manifestation.
Commonly Miscoded HCC groups, cont
Peripheral Neuropathy is a common manifestation
found in DM; to properly capture the correct HCC, the
provider must use a linking statement so the coder can
assign the correct ICD9 codes:
250.60 DM with Neurological manifestations
357.2 Peripheral Neuropathy in DM
Note: Both ICD-9 codes must be assigned to get
proper HCC credit
Commonly coded HCC Groups
496 COPD
493.20 Asthma w/chronic COPD (Chronic
Obstructive Asthma)
491.9 Chronic Bronchitis
492.8 Emphysema
428.0 CHF
425.4 Primary Cardiomyopathy
402.91 Hypertensive Heart Disease w/heart failure
Commonly coded HCC Groups
443.9 Peripheral Vascular Disease
443.81 PVD in other diseases (diabetes)
453.40 Acute DVT
440.0 Atherosclerosis of Aorta
441.4 Abdominal Aortic Aneurysm
Cancer - All malignant neoplasm's including
Melanoma but not skin cancer
All secondary malignant neoplasms
Commonly coded HCC Groups
Diabetes
All diabetes (250.XX) and most of the manifestations
Ischemic or Unspecified Stroke
436 CVA
434.91 Unspecified cerebral artery occlusion, w/infarction
Angina/Old MI
413.9 Angina
412 Old MI
Rheumatoid Arthritis & Inflammatory Connective Tissue Disease
714.0 Rheumatoid Arthritis
Case Study 1
85 year old white female, symptoms of UTI.
Patient is tired, less energy and poor appetite and had a heart attack (MI)
1 year ago. Patient has mild malnutrition, is frail and has lost 30 lbs in the
past 6 months. Urinalysis performed which shows white cells, leukocyte
esterase, and microalbuminuria. Serum creatinine is 1.4. Patient has been
complaining of urinary discomfort, weakness, and has had dry and itchy
skin for the past 6 months.
PMH: Stable diabetes mellitus (DM), chronic kidney disease (CKD)
exacerbated by diabetes, stable BKA, stable history of MI, UTI w/ serum
creatinine 1.3 6 months ago. Lab findings revealed CKD stage 3.
Plan: Glucophase 500 mg b.i.d. for DM. Cipro for UTI. Ensure supplements
for malnutrition. RTC in 3 months. Referral to nephrologist for CKD3.
Case Study 1
Data Mining
Missed Opportunity
Data Mining for DX left on the table
Combo codes that are being coded separately
Patient outreach for refreshing of DX
Data Mining for HCC’s
Data Mining HCC Diagnosis
Increase capture rate
Improves clinical documentation
Provides Education
Focused Reviews
highest potential reward
Problematic issues are put in future training agendas
Data Mining Processes
Example:
CKD
eGFR is a marker for kidney function
Protein in the urine is a marker for “kidney damage”
DM with Neuropathy
Diabetic patient
Pharmacy utilization of: tricyclic, antidepressants AND
Neurontin
Audit Approach
Does the documentation clearly support diagnosis
What is supporting documentation
Treating/Managing Chronic conditions
Medicare rules on “stable” and how is it
documented
HCC Retrospective Audit Approach
Submission Requirements of a Risk Adjusted
Diagnosis
Clinician record must be a result of a face-to-face
encounter
Pathology reports may be used
Encounters must be electronically signed
All diagnosis must be documented and addressed
HCC Retrospective Audit Approach
All documented ICD-9-CM diagnosis codes for each
member
An assessment of provider documentation for
appropriateness, regulatory standards and HCC
eligibility
Identification of coding errors including incorrect or
invalid ICD-9-CM codes
Identification of the potential fiscal impact to the Plan’s
reimbursement profile by identifying HCC opportunities
missed or incorrect in the original file submission(s)
HCC Retrospective Audit Approach
Review and validation of all clinical documentation
relevant to diagnoses:
Documented diagnoses supporting HCCs
Ambiguous documentation in support of potential ICD-
9-CM code assignment
Missed or undocumented diagnoses for (potentially)
current year HCC group assignment
RADV Audits and Process
Management
Risk Adjustment Data Validation yearly process.
CMS verifies the diagnosis codes
The RADV process identifies:
areas of risk adjustment documentation deficiencies,
educational opportunities for physicians and coders.
One best medical record
RADV Audit Issues
Documentation Challenges
One Best Medical Record Limitation
No ability to substitute alternate best medical records where an HCC is not validated on the first record submission.
For example, there may be several medical records that validate the member’s HCC. Requiring plan to choose and submit only one record creates a risk that CMS’s audit results will not reflect the member’s actual health status.
While plan may submit record to submit an alternate HCC, plan may have difficult choice depending on relative strength of the supporting medical record documentation.
No process for addressing situations where records not available because provider is deceased or records were destroyed
RADV Audit Issues
Documentation Challenges, continued
Signature/Credential Requirements
Plans may only use CMS generated attestation forms
during the RADV audit process.
Limited time to address provider questions and collect
needed attestations prior to audit submission deadline.
RADV Audit Issues
Retroactive adjustment issues
The CMS bid process used to establish plan payments is prospectively based.
Prospective payments are based on a plan’s bid estimate of per member costs derived from plan base period data, which is data from a previous year of providing health coverage.
Retroactive adjustments through extrapolation do not take into account that the plans did not bid with these adjustments as an assumption.
Counter Approach
Developing, implementing and maintaining an
effective and efficient compliance program.
Education and Training
Monitoring and Auditing
Reporting and Prevention
Case Study 2
An audit was scheduled to compare the diagnosis
coding on professional (clinic) claims with the
medical record. The client wanted to know:
o Are we reporting all documented diagnoses on our
claims?
o Do we have opportunities for improvement in our
documentation and coding?
Methodology 37
To accomplish the objectives of the audit, Moss Adams utilized
the Hierarchal Condition Category (HCC) payment model
Same model that payers use for risk adjustment
calculations
Similar in concept to the inpatient facility DRG model
Universe of data provided to Moss Adams: all professional
claims submitted to all payers during 2012
Sample of 200 patients selected from the universe
Documentation Requirements
In order for a diagnosis to be captured the
documentation must support one of the following:
The provider is Managing a condition
Evaluating a condition
Assessing a condition and/or
Actively Treating a condition
Risk Categories
Category Risk Area
Diabetes Underlying conditions may not be captured
Cerebrovascular Accident Late effects may not be captured
Acute Myocardial Infarction Acute condition reported during post-acute period
Chronic Obstructive Pulmonary Disease Underlying conditions may not be captured
Depression Documentation may support major depression
Cancer Active treatment vs. history of condition
Chronic Kidney Disease Dialysis status may not be reported
Congestive Heart Failure (CHF) Chronic CHF may go unreported
Sampling Plan
Category
Number of
patients
1 Diabetes 15
2 Cerebrovascular accident/stroke 10
3 Acute Myocardial Infarction 10
4 Chronic Obstructive Pulmonary Disease 10
5 Depression 10
6 Cancer 5
7 Personal history of malignant neoplasm 10
8 Chronic Kidney Disease 15
9 Congestive heart failure 15
10 Random Charts 100
Total Charts Reviewed 200
Summary of findings
Category Client
Data Moss Adams Results
Count of
Patient
Approx
HCC
Weight
HCC
Weight
Variance in
Weight
Potential
HCC
Weight
Total HCC
Weight Increase
(Decrease)
1. Diabetes 15 4.812 4.115 (0.697) 1.800 1.103
2. Stroke 4 2.161 2.450 0.289 0.531 0.820
3. Cerebrovascular Accident (CVA) with
Hemiplegia/Hemiparesis 6 1.923 3.088 1.165 - 1.165
4. Acute Myocardial Infarction (Acute MI) 10 6.241 6.048 (0.193) 5.669 5.476
5. Chronic Obstructive Pulmonary Disease
(COPD) 10 3.400 3.060 (0.340) 1.762 1.422
6. Depression 10 3.600 3.600 - 0.516 0.516
7. Cancer 5 1.854 1.667 (0.187) - (0.187)
8. Personal History of Malignant Neoplasm 10 - 0.676 0.676 0.789 1.465
9. Chronic Kidney Disease 15 8.876 13.729 4.853 10.211 15.064
10. Congestive Heart Failure (CHF) 15 6.524 6.914 0.390 10.682 11.072
11. Other 50 9.147 10.203 1.056 3.160 4.216
Total for 150 Charts 150 48.538 55.550 7.012 35.120 42.132
Payor Specific Claims/Random 50 2.398 1.290 (1.108) 6.492 5.384
Grand Total 200 50.936 56.840 5.904 41.612 47.516
Overall findings
Category Finding
Chronic Conditions • Documented in progress note but not reported
• Medical record reflects condition that was not reported
(problem list, medication list, diagnostic test,
consultation)
• Missed reporting “status” codes
Follow up • Patient not seen during the year
Inaccurate ICD-9 Codes • Documentation supported more specific coding
• Wrong code selected
Other • Documentation appeared to support a more chronic
condition (major depression vs. depression NOS)
• Documentation did not link conditions together
Overall recommendations
Code all conditions that are being managed,
evaluated, assessed and/or treated to the highest
degree of specificity
Link diagnosis with manifestations
Code for status conditions
Review & update problem list
Questions? 44
Thank you for your time!
Lori Laubach, CHC
Principal
253-284-5256
Judy Privette, RHIT, CCS-P
Senior Learning Consultant
The Permanente Medical Group
916-979-4123
45
Save the Date
August 30 - September 2, 2015
34th Annual Conference
Portland, Oregon
