Use hierarchical condition categories when you code
Hopefully, by now, most of you know what MACRA and MIPS are,
but how many of you have heard of an HCC? HCCs are not new. They already play a
role in determining how some of us get paid. They will play a greater role
under MIPS and alternative payment models such as accountable care
organizations (ACOs).
“HCC” stands for hierarchical condition categories. It is
the methodology that CMS uses for risk adjustment.
In the past, while the specificity and completeness of ICD
coding didn’t affect the bottom line, it affected others’. Medicare Advantage
(MA) plans requested records or sent nurses to physician’s office to review
charts to “mine” for diagnoses that weren’t captured in claims. The reason, we
were told, was that by capturing these additional codes, the MA plan could get
paid a higher capitated rate. But it didn’t affect what we got paid for a 99213
or 99214 visit. Or so we thought.
While we were paid fee-for-service by the MA plans, their
financial health could affect their ability to adjust their payment schedule.
Call it “trickle-down economics” for the fee-for-service physicians, which like
its namesake was more of a theory than a reality.
Fast forward to the present. Now, “shared savings” contracts
with MA plans as well as CMS, as a member of an accountable care organization.
While E/M payments are not adjusted based on ICD-10 diagnoses, our choice of
codes makes a big difference in how big the shared savings pool is, since it is
based on risk adjustment using HCC.
For example, rightly or wrongly, one might be in the habit
of using the ICD-10 code 11.9 for all their diabetic patients, and that might
be enough to get you paid for your E/M visits. But if you’re in a shared
savings or capitated program, based on that code, CMS allocates as much payment
to the MA plan or ACO for a diabetic with nephropathy as it would to an
otherwise healthy type 2 diabetic who is diet-controlled. So instead, you
should use the more specific codes, such as E11.21 or E11.22 and include in
your claim the ICD-10 codes for the type of nephropathy (proteinuria, chronic
kidney disease stage, etc.). This moves the patient into a higher-risk HCC.
What if you’re not in a risk-sharing payment structure? Does
any of this matter? Absolutely. One “feature” of MIPS is a “value-based”
payment adjustment that is calculated by comparing your cost for each
beneficiary to the expected per capita cost determined by the risk of your
patients. HCC will be the basis for determining that risk adjustment and how
you code your claim will determine the HCC for your patients.
Using risk adjustment in fee-for-service Medicare is not a
new phenomenon. It’s being used now, in the “value based payment modifier”
(VBPM) that was established in 2013 and is being rolled out gradually (and will
become part of MIPS). The VBPM is an adjustment to traditional Medicare
payments based on the risk-adjusted cost of each physician’s care.
If that doesn’t seem bad enough, the risk adjustment is
based on claims submitted two years earlier, in most cases. In other words, we
should have been coding with HCC in mind a while ago. But it’s not too late.
For more information and or assistance, please call HPP
Management Group:
HPP
Management Group
5201 Blue
Lagoon Drive
Suite 815
Miami,
Florida 33126
Phone:
305-227-2383
Email: pesilverio@hppcorp.com
1-877-938-9311
786-231-7585
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