HIERARCHICAL CONDITION CATEGORIES Association of Clinical Documentation Improvement Specialists Indiana Chapter Indianapolis, IN April 21, 2018

Danita Forgey Consulting, LLC What are HCCs? Risk adjustment system based on diagnosis codes HHS-HCCs ACA plans Adult model (Ages 21 and up) Child Model (Ages 2 – 20) Infant Model (Ages 0-1) Predict current year expenditures CMS-HCCs Medicare Advantage Predict next year’s spending Established in early 2000’s Not all conditions are assigned to an HCC These are chronic conditions actively treated or monitored Used by commercial payers and some variations used by Medicaid HHS - Age determined by age of member at the end of the benefit year Plans can decide not to use a specific HCC if it does not help predict costs for treating beneficiaries, e.g. CMS and obstetrics Also have a prescription benefit RxHCC for part D Danita Forgey Consulting, LLC

HHS HCCs 83 CMS HCCs and < 200 HHS HCCs Demographics built into HCCs Each metal level weighted differently Platinum, gold, silver, bronze, catastrophic Banding Some HCCs restricted to particular criteria Infant risk score based on maturity category at birth and highest level of severity 83 CMS HCCs Demographics – added to risk adjustment score for MA. Commercial payers have HCCs specific to age Other demographics include Medicare or Medicaid coverage, new enrollee vs continuing enrollee, originally disabled vs non-originally disabled and long-term institutional residence (>90 days) Originally disabled – started on Medicare because of a disability Banding – Pregnancy related HCCs cross both adult and child models but are restricted to ages 12-55 Infant risk score – 5 available levels Danita Forgey Consulting, LLC

HCC Hierarchies Age and gender also impact risk score If multiple codes group to the same hierarchy, only the highest weighted HCC impacts risk score HCC If group is listed in this column.. …drop the disease group(s) listed in this column 8 Metastatic Cancer and Acute Leukemia 9,10,11,12 9 Lung and Other Severe Cancers 10,11,12 Patients can have multiple HCCs up to 10 for CMS Danita Forgey Consulting, LLC

Interaction Type High cost and medium cost Only one interaction per patient High cost supersedes medium cost Risk score determined by interaction factor and severe illness indicator SI indicators include HCCs for sepsis, peritonitis, seizure disorders Only qualifies as an interaction with specific HCCs 9 possible high cost and 7 medium cost Interactions and SI are specific HCC groups Not a complete list of SI Danita Forgey Consulting, LLC

Example of Risk Scores ICD-10 Codes HCC Group Demographic Factor Total Community Factor Female 65-69 years 0.312 E10.9, type I diabetes without complication 19 Diabetes without complication 0.104 I5021 Acute systolic (congestive) heart failure 85 Congestive heart failure 0.377 Interaction Diabetes/CHF 0.287 Total Risk Factor 1.08 Danita Forgey Consulting, LLC

How Risk Score Affects Reimbursement Base payment $9,000 Risk adjustment factor 1.08 $9000 X 1.08 = $9,720 Risk score also affected by health plan This means the health plan would receive $9,720 per year for this patient Health plan - platinum, gold, bronze, etc. Danita Forgey Consulting, LLC

Diagnosis Codes Conditions must be documented in the medical record Must be a face-to-face visit Acceptable data sources Hospital inpatient facilities Hospital outpatient facilities Physician offices Submitted at least once during the risk adjustment data-reporting period Danita Forgey Consulting, LLC

Diagnosis Codes Diagnosis codes are not used from the following providers SNF Hospital inpatient swing beds Intermediate care facilities Respite care Hospice Ambulatory surgery centers Home health Free-standing dialysis facilities Health plan can delete submitted codes if they do not meet guidelines for reporting Medicare will not use diagnostic radiology claims Remember issues that may make the FTF encounter invalid: not signed/dated, illegibility Danita Forgey Consulting, LLC

Diagnosis Codes Only submitted according to official coding and reporting guidelines Outpatient coding guidelines to keep in mind Cannot report unconfirmed conditions Codes reported for chronic conditions as many times as the patient receives treatment and care for the condition Codes assigned for all conditions that coexist at the time of the encounter and require or affect patient care or treatment SYMPTOM CODES AND UNSPECIFIED CODES TYPICALLY EXCLUDED NOS is excluded but not NEC Copying and pasting may be a problem if it cannot be determined if the condition is currently under treatment Danita Forgey Consulting, LLC

Diagnosis Codes Follow-Up Medical Necessity History codes Document specific condition being followed Medical Necessity Plans that require prior approval may require specific diagnosis documentation or results of prior diagnostic testing for payment for approval process History codes Code only if impacts current care or treatment Discourage use of “history of” for conditions currently under treatment Danita Forgey Consulting, LLC

Diagnosis Codes Inpatient guidelines for assigning codes for additional conditions Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring Danita Forgey Consulting, LLC

Diabetes HCC 17 Diabetes with Acute Complications HCC18 Diabetes with Chronic Complications HCC19 Diabetes without Complication Link between chronic conditions and diabetes Danita Forgey Consulting, LLC

Cardiovascular Conditions Documentation of tobacco use or exposure Hypertension and related conditions Chronic kidney disease Heart failure and other cardiovascular conditions Specific types of heart failure Hypertension with associated conditions are higher weighted than hypertension NOS CC 1st quarter 2017 says physician has to specify link between HF and systolic or diastolic dysfunction. HCVD. List of conditions assumed to be associatedin the alpha and tabular are not all inclusive. The indexes will be reviewed for modification. Did not specify which heart conditions to include. Could get 3 HCCs for patient with HCVD, CKD stage 4 and CHF Danita Forgey Consulting, LLC

Ulcers and Wounds Ulcers are associated with HCCs Wounds are traumatic or surgical and not associated with HCCs Underlying cause of ulcer Underlying cause – pressure, PVD, diabetes Code stage Danita Forgey Consulting, LLC

Chronic Kidney Disease Dialysis status Acute vs chronic Stage Hypertension Stages 4 and 5 generate HCCs Danita Forgey Consulting, LLC

Documentation Requirements Active treatment of the condition must be reported at least annually. Documentation must indicate whether a condition is currently under treatment or surveillance Plan that specifies treatment for each condition listed Monitored Evaluated Assessed Treated Gives physicians incentive to see patient for at least an annual wellness visit. All HCCs for a given year are reset each year Patient identifier may be DOB. Look at EHR printout to see if identifier prints on every page Monitored - Status of chronic conditions should be documented Look for follow-up visits, referrals, other tx plans Evaluated – response to treatment; lab and radiology; physical exam Danita Forgey Consulting, LLC

Documentation Requirements Entries authenticated and dated Legibility Provider credentials High % of denials due to signature issues Date of service, patient name and an additional patient identifier required on every page in record. Mention CERT report that focused on this and signature guidelines and not so much on inappropriate dx reporting Danita Forgey Consulting, LLC

Data Reporting Conditions for CMS HCCs must be reported by June for initial payment Conditions for mid year payments must be submitted by March Conditions for final year payments due in January of the following year Reported at least quarterly Each data submission should represent approximately 25% of the data submitted throughout the year. EDGE server Danita Forgey Consulting, LLC

Data Reporting RAPS – Risk Adjustment Processing System FERAS – Front End Risk Assessment System Edit system RAPS data – Claim #, dx code, service dates, provider type FERAS and RAPS both generate transaction reports Danita Forgey Consulting, LLC

Optimizing HCCs Review superbills for unspecified codes Review documentation to identify opportunities for greater specificity Review medical necessity denials Timely bill submission Review documentation for legibility and validation Validation of diagnostic findings Validation – confirmation of x-ray results, lab etc. Danita Forgey Consulting, LLC

Resources Centers for Medicare and Medicaid Services, Risk Adjustment Fact Sheet, April 2015 ICD10 University, “The New World of HCCs: What You Need to Know Now”; webinar 1/25/17 Franklin, Janet. "ABCs of HHS-HCCs: Taking a Closer Look at the Commercial Risk Adjustment" Journal of AHIMA 85, no.10 (October 2014): 76-79. 2017 HCCs. April 4, 2016. Available at: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf Danita Forgey Consulting, LLC

Resources CMS; Medicare Managed Care Manual, Chapter 7, Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c07.pdf CMS, ICD-10-CM Official Guidelines for Coding and Reporting, Fy2017 Franklin, Janet. "ACA Risk Adjustment Models Emerge in Commercial Care" Journal of AHIMA 85, no.9 (September 2014): 68-70. Danita Forgey Consulting, LLC

Resources Security Health Plan; https://www.securityhealth.org/provider-manual/shared-content/claims-processing-policies-and-procedures/risk-adjustment---hcc-coding/ Danita Forgey Consulting, LLC