HCC Coding – How can you Maximize Practice Reimbursements?

Good Day everyone

Welcome to Outsource Strategies and our podcast on HCC Coding

Here we will cover a few pointers on steps to reimbursement for your practice.

How can you maximize practice reimbursements? 

In today’s world of value-based care, the need for quality reporting by physicians is growing in importance. Accurate documentation and HCC coding or Hierarchical Condition Categories coding is necessary to report medical care for high-risk, high-complexity conditions.

Since 2004, Medicare has used HCC scores to adjust payments to a health plan based on the level of risk the enrollee presents to a plan, with a higher reimbursement for those with more complex health conditions. In other words, as it costs more to care of your patients with higher HCC scores, Medicare pays their Medicare Advantage plans a substantially higher monthly capitation payment. Treat patients with higher issues, treat patients with more complicated issues, you get paid more. That’s as simple as it gets. Accurate HCC Coding and improved documentation capture the full complexity of the patient, leading to appropriate risk adjustment payment for Medicare Advantage plans and their aligned physicians – that is the goal! 

For 2017, Medicare has made some adjustments. The risk adjustment model includes in our preventive services, which means higher risk codes for plans with healthier enrollees who use preventive services. Well, what does this mean? It basically means that if you are keeping your patients healthy and providing them with preventive services which would prevent them from becoming sick, it helps the plan. It keeps the patients healthy which obviously is a wonderful thing and then it makes sure that the plans can continue to serve patients who have complex conditions as well, without increasing the overall cost.

HCC are based on ICD-10 codes. To generate a risk adjustment factor or RAF score, the HCC payment system uses mainly demographics which is, age, sex, institutional status and ICD-10 diagnosis codes. Appropriate diagnosis code reporting and complete clinical documentation by physicians increases the accuracy of member risk codes because these risk scores determine the reimbursement. The risk scores also determine the level of care that is being provided to the patients which is very important. You know some HCC coding tips to help physician practices improve reimbursement. Obviously, that is what we want to try and convey to you today, We always want people to be aware of what you are doing when you are with the patients, what are the level of patient’s conditions. You have to always code to the highest level of specificity. To give you a perfect example: for a patient with diabetes2, uncomplicated, the risk adjustment factor is .118. However, if the patient has chronic kidney disease or CKD stage3 from diabetes, the code for diabetes with CKD-3 should be used which has a higher RAF score of .368. Similarly, if they have diabetes2 with neuropathy, that also has a score of 0.368. Here, there are two reasons for providing specificity – one being that you are obviously reporting a higher complexity on the patient which increases your reimbursement, but you are also providing the right information to Medicare letting them know that the issues the patient is having, which makes sure that the coverage given to the patient is correct.

• Next point would be: maintain HCCs from a prior health plan if relevant. Patients move form doctor to doctor, move from office to office. If a new patient that has presented in your office already have an assigned HCCs from a  prior health plan, these should be maintained if relevant to support continuity of care and complete data collection. Why do you say it relevant?  Well, if the patient is presented with diabetes for the previous insurance company or the previous physician office, well now the patient could be coming to you for something completely different. So, obviously the HCCs will not the same, it will be different. So complete data collection is very important and continuity of care needs to be maintained whenever appropriate.

• Ensure comprehensive documentation: So important for many factors including continuity of care. Each patient’s demographic information and clinical details should be accurately documented in the medical record. Clear, accurate, legible, and thorough supporting documentation is necessary to support the diagnostic codes assigned.
• Now here is the MEAT part. This is another point. Adhere to MEAT.
  What is MEAT? MEAT is the acronym for Monitoring, Evaluating, Assessing or Addressing and T would be Treatment. So to capture a diagnosis code on a particular date of service, documentation should adhere to MEAT criteria: Monitor – signs, symptoms, disease progression, disease regression; Evaluate – test results, medication effectiveness, response to treatment; Assess/Address – ordering tests, discussion, review records, counseling, and Treatment -medications, therapies, and other modalities. So if you follow the process of MEAT, to repeat, it is basically monitoring of the patient, evaluation, assessing and addressing and then the treatment, you will cover your documentation correctly and that will make sure that you review your HCC codes correctly, but now you can get into the HCC codes to specificity that is required and now the reimbursements are better and your reporting is perfect.
• Performing chart reviews: Now this may sound like something that – where do you have time to do this? Good question. It is not about time. It is the fact that if you do proper chart reviews, it will help you identify maybe some documentation errors. You can also prevent risk adjustment data validation (RADV) audits. You don’t want to get audited, none of us do. So the best way to do it is to make sure your documentation is correct. 
• Ensure consistent HCC capture: CMS expects HCCs to be captured once every 12 months. Therefore it is important to monitor patients’ HCCs to ensure consistency in reporting. If a patient’s HCCs are dropping, it could indicate gaps in care or failure to accurately document services that were provided. It has two problems here. One, on a reimbursement level, now your HCC is dropping, that basically means that your reimbursements will drop and the other hand, maybe your treatments that have not been documented correctly will not allow you to provide good continuity of care. So it is always good to ensure consistent HCC capture and monitoring of that.
• Stay up-to-date with coding: I don’t thing that is something that any of us needs to be reminded of. It is something that is very important. ICD-10 codes are subject to yearly changes and staying up to date with these changes is crucial to ensure accuracy in reporting.

We just covered a few different points and I just wanted to make sure that these points were looked at while you run your practice and you keep moving forward. Hopefully these were helpful. Please tune in and listen to more podcasts at Outsource Strategies. We look forward to hearing from you. If you have any questions or suggestions, do let us know.