Wiki HCC Coding Documentation

[AB87]

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

 

[LilMissCoder]

I guess my first question would be how do you know the patient has COPD? If the only evidence of COPD is the script, I would not code it. Advair can be used for asthma, chronic obstructive broncitis, and a variety of other illnesses, not just COPD.

You could query the provider and ask him to address the issue, but coding for HCC isnt any different than any other type of coding. Your documentation must support the use of the code in order for you to be able to use it.

 

[martinni1974]

I work for a part C healthplan and I can tell you that a med list alone does not substantiate an HCC. Take a look at the link below. Additonally, you should review CMS's risk adjustment requirements.

http://news.aapc.com/index.php/2013/03/top-10-medicare-risk-adjustment-coding-errors/

Good Luck!

 

[jharo1733]

The answer is no. The provider must write out all diagnoses that affect the plan / treatment of the patient in narrative form in the medical record. They also must show MEAT...how they were monitored, evaluated, assessed or treated.

 

[AB87]

Thank You all for your replies! They made it a rule that we can match a Medication to an HCC. The rule states for COPD We can use a Med that is only treated for COPD and we can match a Blood Sugar med (Metformin, Glyburide, etc..) to Diabetes. To me this is stretching it to our Advantage and this is all doumented in our New Policy Procedures.

 

[LilMissCoder]

If your company is involved with a gain share contact for HCC coding, you need to be aware that they will be coming in and auditing each and every year. They will want to see that the HCC codes that you've submitted are backed up with an actual assessment and a medication list will not uphold that. These drugs are not soley used for the conditions that you state. I've seen Metformin given to a patient that is in the prediabetic catagory. It would not be ethical to give the patient a diagnosis of Diabetes based on a medication list, especially if the provider has never assessed that condition one way or the other.

Its my opinion that seeing those meds should prompt you to query your provider for a diagnosis and assessment, but its beyond a coders scope to add a dx code using info from a medication list.

 

[AB87]

Well in the Notes the Patient does have Diabetes. But thats the only support is the Med. Were not assuming they Have DM, to me i just think Metformin or any other blood sugar drug alone is Weak Support. They want something that has a CMS stamp on it that says you cant match a Med to an HCC. This is my biggest issue is getting a Publication from CMS that says that.

 

[ajudd]

documentation

You should not code based on a medication list. The patient could be pre-diabetic, etc.

The physician must indicate in the notes. Now, if DM is in the PMH and current medication list says person is on Metformin, then by all means pick up the appropriate 250 code.

Remember, each note also must stand alone. Every HCC must be on a note that supports itself.

You need to be careful, because if you get called for a RAD-V audit you open yourself up to discrepancies and potential financial loss. Coding is gray enough with out assuming patients have something based on a medication. Also, I try to keep in mind - even though notes are stand alone - if I don't see something often it could be a typo and I am leary about reporting it.

For example, if in the entire reporting year - you see one mention of diabetes and that is it - no medication, no nothing. I am cautious that the transcriptionist made an error, the doctors Dragon device, etc... whatever - I just can't help but wonder if it's accurate if I see something once and that is it. Generally, most conditions are chronic so you expect to see them frequently in a medical record. unless - of course - the comment says newly diagnosed.

Just be cautious. Don't give someone a condition they don't have and don't assume that just because they are on something you know what condition it is for. Many medications have multiple purposes. You want your note to support itself and there be no question if that person is the one in the RADV audit.

 

[arathialex17@gmail.com]

you can very well code COPD in this case because COPD is a life long condition and as per the guildline minimal plan is enough to code these conditions, hence COPD can be coded taking Advair as plan.