Documentation Challenges with HCC Coding

The Centers for Medicare and Medicaid Services (CMS) has mandated the Hierarchical Condition Categories (HCC) as the basis for reimbursement for Medicare Advantage (MA) plans. HCC uses demographic information such as age and major medical conditions documented in the previous 12-month period to estimate predicted costs for enrolled members in the next year of coverage. Under this risk adjustment model, providers receive higher payments for treating high-risk patients. Accurate HCC coding is therefore the key to receiving appropriate compensation for treating high-risk enrollees in MA plans.
 
Capturing HCC accurately

MA Plans use ICD-10-CM codes as the primary indicators of each member’s health status. Health care providers need to capture the complete diagnostic profile of patient, including all diagnoses that affect the patient’s evaluation, care, and treatment such as:

•   The nature of the presenting problem
•   All chronic conditions (for e.g., congestive heart failure, chronic kidney disease, rheumatoid arthritis, diabetes with manifestations, all active cancers, etc.)
•   History of relevant past conditions
•   V codes (which describe encounters with circumstances other than disease or injury)
•   E codes (external causes of injury and poisoning)

While ensuring comprehensive documentation is necessary for proper risk adjustment reporting, there are many challenges involved in this context:

•   In the cumulative HCC model, a patient can be assigned more than one HCC category depending on all chronic disease processes and manifestations that are both active and/or have a history for the enrollee
•   Each disease group relates to a specific medical condition (e.g., diabetes and congestive heart failure)
•   To accurately report the chronic disease process for linking to the appropriate HCC, documentation must contain linking statements for all disease manifestations that have been identified (e.g., “diabetes with hypertension and diabetic neuropathy)

In addition to coding to the highest level of specificity, physicians need to ensure timely reporting of the information to CMS.

Medical Coding Services help Avoid Missed Revenue Opportunities

HCC coding is unique in that accuracy can be assured only through a complete understanding of the HCC process and risk adjustment, the impact on the provider as well as the enrollee, the MA plan, and overall reimbursement. As a report published by the American Academy of Professional Coders (AAPC) pointed out knowledge is paramount to recovered reimbursement.  Missed payment opportunities are the result of plans not being able to provide CMS with accurate HCC data collected from providers. Appropriate documentation and coding are essential to prevent significant financial losses for MA plans. Only medical coders who have been trained in Hierarchical Condition Categories coding can ensure this.

The professional teams in a reliable medical coding company works with physicians to build HCC coding and EHR documentation efficiency and implement measures to assist them in improving documentation standards. With timely and accurate HCC coding, the right medical coding service helps physicians avoid missed revenue opportunities.

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