Wiki HCC Coding Documentation - HCC Diagnosis

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AB87

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We are having a Debate on if we are allowed to use a Medication list as the Sole support of an HCC Code. Example, if the patient has COPD and the only support in the Medical Record is Advair (from a medication list), Is this the correct way to support an HCC Diagnosis? Could anybody please send a CMS Document showing proof stating otherwise.

Thank You
 
No it is not. If the patient is coming in for review of chronic conditions then it should be listed in the HPI. COPD-per patient using medication as directed, no new complaints.

And it should also be listed in the medical history. Patient has a history of COPD since 1/2009 or however he/ she wants to document it.

I'm the HCC Coding / Education Account Mgr for my organization. Please let me know if you have any other questions.

Remember in order to establish relevancy in the Dx, Assessment and Plan you need to have mentioned it, examined it, or referenced it in the Body of the note.

Hope this helps.

PS your description in the OP is what we would call a SUSPECT condition one that we would query the doctor about so he can then document it.
 
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Thank You! You are the thrid source that has told me that, My big issue is that if we have a Past Medical Hx and it states (DM type 2, COPD) and the ONLY support for Both is From a medication list they want us to still code it. Which i dont agree with because when i first started i remember that you cant use a Meds List as the Sole Support of an HCC.

With EMR its always an issue and most of the time when COPD/DM Is in the past medical Hx it never has a Date, If it did i would code it. But thank you again, It was a bunch of help! :D

PS,
usually when i come across COPD Its never suspected, Its always just in the EMR But no additonal Support to show it was actually Addressed. I could get this "New Rule" changed but they want something from CMS stating specifically saying that "Medication List cannot be the sole support of an HCC and needs more Support". Ive shown them a Guide about CMS-HCC from Scan Health Plan, but i was told that "Thats there way of Coding and we cant use that because it has there Company print on the Guide"
 
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What you are describing is "laundry listing" and will be kicked out by any auditor in the HCC world.

The DAT must be supported within the body of the note either usually found in the HPI or Medical History.

The diagnoses should Never be assumed from a medication list. It is understood that the disease process is treated by the medication BUT the diagnosis had already been made, assessed and the treated. (does that make sense?)

The way your physicians wish to do it is considered unsupported and would be thrown out in the event of a RADV audit, which would reduce the RAF score and possibly result in take back situation.
 
Only in cases of breast cancer and prostate cancer and Insulin for Diabetes....those are the only times medicine can be directly used to code an HCC, but the record still needs to indicate they have cancer/diabetes....you cant code from medicine alone. Hope that helped
 
You might want to consider having the provider (or whoever is telling you to code based on Rx alone) watch the AAPC webinar from January 2013, "HCC Coding and Docuentation: A Coders View" by Susan WYatt. This pretty clearly details that more than a med list is required to support a diagnosis. I think the third slide in states, "Provider must see patient once a year at a minimum in a face-to-face visit and document the chronic conditions in a SOAP note making sure all diagnoses have statuses and plans." Providers also need to consider that meds may be used for different reasons, such as Advair can be used for asthma or COPD, one risk adjusts and one does not, so you can not assume that COPD is the diagnosis. Good luck!
 
HCC coding on COPD

I agree with what everyone is telling you on not having a medication list alone for COPD support. It is unfortunately that I have worked on some projects where they had a so called chronic list and if a diagnosis is on this list we should code it no matter what. I think this puts providers in a bad trend of not properly documenting the patient's condition (as they already do this already).
 
Agree with kksmom on this topic, as the HCC coding educator for my organization, we are conservative in this and require that the chronic conditions not only be stated in the HPI or past medical history/chronic condition list or med list but a status and plan be given by the provider in his/her assessment and plan. There are a few exceptions to this rule; things such as amputation status, ostomy status, insulin-use and dialysis status. In short it is of utmost importance that providers document the status of chronic conditions in their assessment/plan everytime it is pertinent to the visit and that avoids any and all confusion. With that education in hand there can be no doubt as to whether it should be coded or not.
 
Evaluative Statements

Code all documented conditions that coexist at the time of the encounter/visit, & require or affect patient care treatment or management. Please remember to document an evaluative statement for each chronic condition (i.e. stable, worsening).

Here are some links to CMS which give information on HCC documentation requirements:



Medical history alone may not be used as a source of diagnoses for risk adjustment purposes. For a
chronic condition to be accepted for risk adjustment, the patient must have a face-to-face visit each year
with a provider/physician who assesses and documents that condition.

http://www.csscoperations.com/Internet/Cssc3.Nsf/files/2013_RA101ParticipantGuide_5CR_081513.pdf/$File/2013_RA101ParticipantGuide_5CR_081513.pdf


https://www.cms.gov/Medicare/Medicare-Advantage/Plan-Payment/Downloads/radvchecklist.pdf

Centers for Medicare & Medicaid Services
Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c07.pdf

Risk Adjustment Data Submission Requirements

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c07.pdf
 
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A medication list is not enough to substantiate a code for HCC submission. There needs to be language connecting the COPD to the medication. There should be additional substantiation including a status of the condition and a plan of care. It should be clear the condition was addressed with the patient.

Mrs. X is on Spririva for her well controlled COPD. Continue Sprirva, return in 6 months.

'Well controlled' is the status; 'continue Spiriva' is the plan.

All conditions must be substantiated (menaning there must be more then mention of the condition); Documentation of monitoring, assessing, evaluating and/or treatment will substantiate the condition.
 
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