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Risk Adjustment Hierarchical Condition Categories (HCC Coding)

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BEST PRACTICE TO MANAGE CMS RISK ADJUSTMENT TIMELINE The Centers for Medicare and Medicaid Services (CMS) recalibrates Medicare Risk Adjustment (MRA) scores for health plans’ Medicare Advantage members three times each year. Paying close attention to deadlines and changes in regulations can help the plan and providers avoid costly adjustments as CMS calculates the risk scores that determine a Medicare Advantage member’s premium based on the data that you submit. Allowing adequate time for medical record retrieval, abstraction and validation is crucial in substantiating diagnoses codes that capture the Hierarchical Condition Categories (HCC) that CMS uses to assess risk and adjust payments.

BEST PRACTICE TO MANAGE CMS RISK ADJUSTMENT TIMELINE Data must be based on face-to-face visits with care providers and submitted before one of the three deadlines for a payment year, depending on the date of service, which could be within three months of the data submission deadline. You must ensure that your encounter data is accurate in order to preserve, or perhaps increase, the amount of your monthly risk adjustment payment.

2019 HCC UPDATE

WHAT IS HYPERTENSION Hypertension is another name for high blood pressure. It can lead to severe complications and increases the risk of heart disease, stroke, and death. Blood pressure is the force exerted by the blood against the walls of the blood vessels. ... Unmanaged hypertension can lead to a heart attack, stroke, and other problems.

PRIMARY HYPERTENSION

HYPERTENSION

HYPERTENSION When assigning diagnosis codes for hypertension (HTN), there is an presumed causal relationship between hypertension and heart involvement, and between hypertension and kidney involvement. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated Documentation must support the presence of the condition and indicate the provider’s assessment and/or plan for management of the condition.

=-- ==- --· ----- ----- -::,-;;-.=-.:-::-:.-=-: =---.:·.:-::--=- ...... ... __, -.......-. ...... .-._--_ .,_ , .....-.---....... --· =-- ==- - -=--:.-= -=== -- ----- ----- ICD-10 - CM Guideli n 1e s ""The Basic Five .,., 1 . The 1st listed ,d x identifies the ---·---- -------·---·--·-·------·------- ;=::=-.-.===:.=-=----=:-=:.----=-.=.---=-=-=== -::,-;;-.=-.:-::-:.-=-: =---.:·.:-::--=- co1n d it i o n requiring the greatest -=--:-=-:-.-.=--.:--=-.-------:---:--·=-.-.--:-:.--:·- work effort as determ1in e d c l in ic ia n 1 and s u , p p o rt e d l i 1n by the t h ,e m e d lic a ll record. cdcgov llChs,lcd od10cm Code all conditions that require or affect care. Code reason1s for all s t u d i,e s . Code to the highest level of specificity known. Do n1o t use "rule out" for unconfirmed 1dlia g n o s e s ; instead report k1n o w n signs and symptom1 s .

C1 - ·- ICD-10-CM Guidelines ............................e..ia....... - - ---:a-:..-.. --.:·::-...-..... .......1....... ..,._.Jilt. ICD-10-CM Guidelines linica / O,o cumentation Improvement C1 9. 1Co1 m bination Code A combination code is a single code used to classify: Two diagno ses, or A diagn osis with an associated - ==------=--==:=.---== ·- =-..=.. ...:.:;:.;::.::; -:;=.: cdc gov nchs(ICd icd10cm secondary process (m anif est a,t io n ) A diagnosis with an associated complli cat io n ICD-10-CMOfficial Gutdelines, SectionI: 8.9: pg 15-16 J. Code all documientedl conditi1ons that 1C0 1exist at th e t ime of the encount er/ visit, and require or affect patient care treatment or management.

ICD-10-CM Guidelines Updates Chap1 ter 9: Diseases of the Circulatory System {100-199) 1 a. !Hype rt ension (Effective Oct 1, 2016): The classification presumes a 1causal relationship, between hypertension and heart involve1ment and between hyp,ertension and kidn,e y iinvolvement, as the two cond'itions aire !li nked by the term "with" in the Alphabetic Index .

HYPERTENSIVE WITH HEART DISEASE:

HTN & HYPERTENSIVE CRISIS:

HYPERTENSIVE HEART OR CKD:

HYPERTENSIVE HEART AND CKD DISEASE: If a patient has multiple conditions code the following:

HYPERTENSIVE HEART AND CKD DISEASE:

CODING GUIDELINE CH:9 DISEASE OF THE CIRCULATORY SYSTEM

HYPERTENSION AND LINKED CONDITIONS (LETS REFER TO THE CODING TOOL)

CODING HYPERTENSION

HCC PAYMENT:

HCC

THANK YOU FOR PARTICIPATING QUESTIONS Mechelle Reed, Associate Vice President Risk Adjustment mreed@universalcare.com The next CMS Sweep Date is 09/2019. All supplement date should be received on or before August 10, 2019.