By now, almost all healthcare providers have been affected by the shift to value-based care and are either working with or are aware of hierarchical condition category (HCC) coding. It is practically impossible to participate in Medicare and not be subject to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Consumer Assessment of Health Providers and Systems (CAHPS), or other programs that adjust payment based on quality and cost. In addition, with this change, it can be difficult to manage the clinical documentation and diagnosis coding that impacts the population risk-adjustment factors that improve financial opportunity.
The Centers for Medicare and Medicaid Services’ (CMS) HCC model was created to capture diagnosis codes that better reflect individual patient risk for predicting future healthcare expenditures. The Medicare Shared Savings Program (MSSP) and Medicare Advantage use HCCs to help set financial benchmarks for budgetary performance. The best approach to capturing HCCs is a combination of provider education, technology, and patient engagement.
Traditionally, medical record documentation was a way for providers tell the patient’s story, communicate with other providers, and justify the evaluation and management (E&M) coding by capturing the time and complexity of the encounter. This worked well in fee-for-service (FFS) models. Now, with the focus shifting to fee for value (FFV), providers need to also focus on capturing important elements about each condition and diagnosis, coding to the highest degree of specificity.
Certain specific ICD-10 codes will map to specific HCCs, which carry a risk adjustment factor for that patient. For chronic conditions, the chart documentation and ICD-10 coding needs to be completed each year to recapture the HCCs. Once providers are educated in this paradigm shift, the next phase is to support them through continued training and technology.
HCC Capture and Recapture
There are two very important ways that technology can support providers in capture and recapture of HCCs each year. Once an HCC has been established, it is usually subject to mining and analytics from either claims data or the electronic health record (EHR). Reminder systems can be put in place so these patients are targeted each year for annual visits and HCC recapture.
Special care must be taken to not code for HCCs that were acute and where the condition no longer exists. In some cases, claims and EHR data may suggest a diagnosis that has yet to be documented that can map to an HCC. An example of this may be a patient with abnormal pulmonary function tests and who is taking long-acting respiratory medications but has yet to be diagnosed with chronic obstructive pulmonary disease (COPD). Analytics can help identify these patients for potential HCC capture.
Annual HCC Capturing
Capturing HCCs on an annual basis requires a face-to-face visit with the patient. Annual preventive visits, welcome to Medicare exams, and annual wellness visits are good opportunities to capture your patients’ HCC conditions when they visit the office. In addition to being a great opportunity to connect with patients, these visits are designed to encourage monitoring of physical and cognitive abilities. They also help with development of plans associated with decreasing the impact of increasing frailty on everyday life for seniors. These visits are of no cost to patients and meet CMS’s obligations.
Learn about the impact of population risk adjustment and the role of HCCs by developing provider education, employing technology, and designing patient engagement strategies to achieve your goals.
Douglas Ardoin, MD, MBA, is managing principal for Lumina Health Partners.
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