Oncology & Hematology Coding Alert

SDoH guidelines, HCC realignments, and a new BPH ablation procedure share the spotlight.

Things change rapidly in the world of oncology coding, so it’s important to stay on top of each new development as it happens.

Here are four recent updates to ICD-10-CM guidelines, Centers for Medicare and Medicaid Services’ (CMS’s) Risk Adjustment Hierarchical Condition Category (HCC) model, and HCPCS Level II codes. If you missed them when first announced, don’t worry. Here’s the scoop moving forward.

1. Get Familiar With This New ICD-10-CM SDoH Guideline Change

In addition to adding the codes we outlined in the reader question “Don’t Be an April Fool and Ignore These New Dx Codes” (Oncology & Hematology Coding Alert, Vol. 25, No. 4), ICD-10-CM updated its social determinants of health (SDoH) guideline I.C.21.c.17 to read “conditions or risk factors that influence a patient’s health should be assigned when documented in the patient’s medical record.”

ICD-10-CM has also removed the part of the guideline instructing you “to code as many social determinants of health that are necessary to describe all of the social problems, conditions, or risk factors documented during the current episode of care.” But this is, perhaps, ICD-10-CM’s removal of redundant language, because you are always free to assign as many codes as needed to paint the full picture of a patient encounter.

(To see the full ICD-10-CM updates effective April 1, 2023, download the document https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf.)

2. Start Making SDoH Coding a Priority

The constant addition of SDoH codes to ICD-10-CM reflects recent updates to CMS’ Framework for Health Equity, an ongoing initiative to advance health equity among underserved and disadvantaged populations. Paramount among the framework’s five priorities is expanding the “collection, reporting, and analysis of standardized data,” which means capturing “demographic and SDoH data, including race, ethnicity, language, gender identity, sex, sexual orientation, [and] disability status,” according to CMS.

So, while we are not yet at the point where CMS or other government agencies are requiring or even mandating the collection of SDoH data using codes from Z55-Z65, CMS’ prioritizing of SDoH data collection in the Framework for Health Equity initiative represents a significant step in that direction.

(For more information about the CMS Framework for Health Equity, go to www.cms.gov/files/document/cms-framework-health-equity.pdf.)

3. Know These Key HCC Model Proposed Changes

Oncology practices should also be preparing for the switch from version 24 to version 28 of CMS’s Risk Adjustment HCC model.

As a reminder, “risk adjustment is a process by which health insurance plans are compensated based on the health status of the people they enroll, thereby protecting the insurer against losses due to high-risk, high-cost patients,” according to Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, of Granite GRC Consulting in Salt Lake City, in her 2021 RISKCON session “Risk Adjustment for Beginners.”

Additionally, accurate and complete reporting of specific conditions to paint the full picture of a beneficiary’s health is also important for an increasing number of entities as they form, participate, or join an Accountable Care Organization (ACO). Both risk adjustment for payers and ACO entity models will be affected — though in different ways — by these updates to the HCC versions and the inclusion/exclusion of the resulting HCC changes.

Medicare’s calculation of an illness’ severity is HCC-based, which in turn is ICD-10- CM-based. So, ICD-10-CM coding compliance is paramount. Additionally, the payment is adjusted based on patient demographics such as age, disability, financial status, and institutional status.

The proposed model change will increase the number of reportable HCC categories from 86 in version 24 to 115 in version 28 and will carry a significant decrease in the number of ICD-10-CM diagnosis codes that will map to the 115 HCC categories. Under version 24, CMS used 9,797 diagnosis codes compared to 7,770 codes that will risk adjust in the version 28 model.

You may be asking how the new mapping affects your oncology/hematology practices and what you can look forward to. Take a look:

• In version 24, C50.- (Malignant neoplasm of breast) mapped to HCC 12 and will now map to HCC 23. Unfortunately, at this time we cannot speculate on what the weight for the new HCC category will be or how the risk adjustment will change.
• CMS will also no longer consider many other codes associated with oncology/ hematology as HCCs, such as D70.1 (Agranulocytosis secondary to cancer chemotherapy), which mapped to an HCC in version 24 and will carry no risk adjusted weight in version 28. CMS will also not map other diagnoses, such as D75.82- (Heparin induced thrombocytopenia), D69.8 (Other specified hemorrhagic conditions), D70.3 (Neutropenia due to infection), and D84.82- (Immunodeficiency due to drugs and external causes) to an HCC in the new HCC model.

Why the change? “Since the implementation of ICD-10-CM, CMS has been collecting and analyzing ICD-10-CM coding patterns/trends and their impact on the associated health costs. Using that information, CMS has worked with clinical and medical experts to identify coding variation compared to the inaugural HCC logic resulting in the version 28 adjustments that better reflect these coding variations on healthcare costs. As a result, these findings are driving material changes to the HCC system and, in turn, impacting payer and provider shared savings program payments,” observes Kelly Loya, CPC, CHC, CRMA, CPhT, CHIAP, Associate Partner at Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina.

(To view the full Methodological Changes for Calendar Year (CY) 2024 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies, download the document www.cms.gov/files/document/2024-advance-notice-pdf.pdf.)

4. Become Familiar With These Important Drug Additions

HCPCS Level II has introduced 11 new codes for drugs that may come into play in oncology settings:

• C9145 (Injection, aprepitant, (aponvie), 1 mg)
• C9146 (… mirvetuximab soravtansine-gynx, 1 mg)
• C9147 (… tremelimumab-actl, 1 mg)
• C9148 (… teclistamab-cqyv, 0.5 mg)
• C9149 (… teplizumab-mzwv, 5 mcg)
• J0218 (… olipudase alfa-rpcp, 1 mg)
• J1411 (… etranacogene dezaparvovec-drlb, per therapeutic dose)
• J1449 (… eflapegrastim-xnst, 0.1 mg)
• J1747 (… spesolimab-sbzo, 1 mg)
• Q5128 (… ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg)
• Q5130 (… pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg)

(You can download a zip file with all the recent changes by going to www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.)

Take This Important Advice

Now is the time to start educating your providers and staff regarding the upcoming changes that will affect not only the Medicare Advantage providers, but those who are associated with an ACO, as the changes are going to greatly impact the HCC reporting requirements under the ACO agreement and directly affect the shared savings that come along with proper HCC capture.