Wiki Understanding HCC Process

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lhoot

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Hello,
Is HCC coding something done separately and in addition to regular, accurate coding of a visit or are the codes needed to capture HCC diagnoses garnered from the codes already being found for reimbursement? Some of the information I'm seeing sounds like this is a whole different process of coding and yet other information seems to be a matter of just pulling out diagnoses from what should be an accurately coded visit.
Laura Hoot, RHIT, CCS
 
The codes come from what are assigned at the time of coding, it's not a totally separate process. However, if the diagnoses are not coded to the highest specificity, accurate, or complete the true complexity of the patient will not be shown.

Snippet from links above:​

Medical Coding for Risk Adjustment​

While all risk adjustment payment models differ in some areas, one common ground they hold is diagnosis coding. Risk adjustment is a payment methodology that uses ICD-10-CM codes, organized into Hierarchical Condition Categories (HCCs), to establish a risk score for each patient.

Medical coders have a special role when it comes to coding for risk adjustment, and there are measures they can implement to increase coding accuracy. Whether an HCC coder (also referred to as a risk adjustment coder) is coding for a physician’s office, a health plan, or a government auditing contractor, they need to understand the complexity of diseases associated with chronic conditions or comorbidities to ensure the documentation supports the accurate health status of the patient. Medical terminology, anatomy, and pharmacology are additional areas of expertise required of competent risk adjustment coders.

Keep in mind, what might be “good enough” to establish medical necessity on the fee-for-service (FFS) claim may not be specific enough for accurate risk score calculation. As Scenario 1 shows, HCC coding relies on all documentation available, not just the provider’s final assessment, for a date of service. The scenarios below use HCCs from the Centers for Medicare & Medicaid Services (CMS).
 
Thank you very much for the references. The scenario you mention, Scenario 1, is an example of the basis for my initial question. The scenario states, “The physician addressed the questionnaire with the patient, asked some more pertinent questions, and listed moderate recurrent major depression in the final assessment.” A correctly coded record should have coded F33.1 for the moderate recurrent major depression. I'm not sure why the coder in this scenario coded F32.9. However, if the coder chose the correct code, F33.1, then this would have been correct for medical necessity, as well as, a good HCC diagnosis. I’m understanding this to mean that if the record is correctly coded according to the coding guidelines, then HCC’s should be accurately picked up from those codes. Let me know if if that's not right.

Laura
 
lhoot said:
Thank you very much for the references. The scenario you mention, Scenario 1, is an example of the basis for my initial question. The scenario states, “The physician addressed the questionnaire with the patient, asked some more pertinent questions, and listed moderate recurrent major depression in the final assessment.” A correctly coded record should have coded F33.1 for the moderate recurrent major depression. I'm not sure why the coder in this scenario coded F32.9. However, if the coder chose the correct code, F33.1, then this would have been correct for medical necessity, as well as, a good HCC diagnosis. I’m understanding this to mean that if the record is correctly coded according to the coding guidelines, then HCC’s should be accurately picked up from those codes. Let me know if if that's not right.

Laura
Click to expand...
Yes, you are correct. If the record is correctly coded to the highest specificity and including all appropriate co-morbid conditions then HCCs will be accurate.
 
lhoot said:
Hello,
Is HCC coding something done separately and in addition to regular, accurate coding of a visit or are the codes needed to capture HCC diagnoses garnered from the codes already being found for reimbursement? Some of the information I'm seeing sounds like this is a whole different process of coding and yet other information seems to be a matter of just pulling out diagnoses from what should be an accurately coded visit.
Laura Hoot, RHIT, CCS
Click to expand...
Why are HCCs important and why do they need addressed? Take a quick listen to
Talking HCCs with Dr. Victor Singzon, MD, FAAFP, CMIO and Leyna Belcher, WVUM CDI Educator as they discuss Hierarchical Condition Categories (HCCs) and their importance in accurate healthcare documentation.
You can listen to the podcast here or on Spotify.
Follow WVU Medicine Documentation Matter for more upcoming episodes.
Click to expand...
 

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