Coding specificity, education, and CMS monitoring are key for capturing Hierarchical Condition Categories.
This article was originally published June 27, 2018, on HCPro's Revenue Cycle Advisor.
Although Hierarchical Condition Categories (HCC) are not new, the risk-adjustment methodology is beginning to surface more frequently in both the acute and primary settings.
HCCs can be a prospective approach to paying providers or health plans for the care provided to patients, explains Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer of First Class Solutions, Inc. in Maryland Heights, Missouri.
Here are three strategies for improving physician documentation and compliance around HCC capture:
Consider coding specificity
Often, Dunn says, HCC payment is driven by the number of conditions that the provider monitors, evaluates, assesses, or treats (MEAT).
“Chronic conditions are especially important to MEAT and, therefore, code and claim,” says Dunn, a member of the advisory board for HIMB.
The codes submitted by the hospital and physician office contribute to the HCCs that patients may accumulate during the year. Dunn says that reimbursement for the patient’s accumulated HCCs is based on the risk adjustment factor (RAF) and the conversion factor for the year, otherwise known as the denominator.
Coding specificity is a major part of HCCs because less than 10,000 ICD-10 codes qualify for the 79 HCCs, says Dunn. But specificity also heightens the need for outpatient clinical documentation improvement (CDI).
“This serves as an ideal opportunity for coding professionals to take on this concurrent role in physician practices,” says Dunn. “Outpatient CDI should occur while the physician has the patient’s current status fresh in mind. Unlike inpatient CDI, the review of the record should take place on the same day rather than waiting until the next business day.”
Educate physicians, staff
The coding professional’s knowledge of coding requirements is especially important when educating scribes who may work in the practice. The scribe can help capture some of the specificity—in real time—when he or she is with the physician and the patient, Dunn notes.
Education is also important for physicians and the entire staff, says Dawn Diven, BSN, RN, CCDS, CDIP, a CDI specialist at West Virginia University Medicine.
“You have to educate staff on what HCCs are and how they impact the patient’s chart,” she says.
Physicians need to understand that the purpose is not to upcode or capture as many as HCCs as possible, Diven says. It’s about accuracy. Sometimes accuracy may mean less reimbursement, she notes. Other times it may mean some Patient Safety Indicators on the inpatient side.
“We make sure that in CDI everything is about accuracy; there is no pressure to move a DRG to make more money,” she says. “If you focus on the chart and what is exactly going on with the patient on the outpatient setting and inpatient side, why they are here and what is exactly going on, all the MCCs, CCs, HCCs, and reimbursement will take care of themselves.”
The team at West Virginia University Medicine also discussed compliance and what is appropriate in the outpatient setting. They looked at charts and pulled the history and physical, plan of care, and assessment to explain to physicians where they need to document and what terminology they need to use so the coder can accurately capture the correct code.
Look to CMS for data, guidance
There currently isn’t federal data on HCC details and capture rates, but CMS is expected to release that information at some point to provide a better picture of what is happening across the industry.
Some MA companies and organizations may issue reports on the data they collect, However Sonia Trepina, MPA, director of ambulatory CDI services at Enjoin CDI, a physician-led clinical documentation integrity company, cautions HIM directors to be aware that insurance companies, like health systems, could interpret guidelines differently in accordance with their own internal policies, therefore creating variances in data sets of HCC capture information.
“There is vagueness out there when it comes to risk adjustment, so the industry needs to be very clear on what gets counted toward an HCC versus what does not get counted and why,” she says.