Wiki HCC coding - ICD-9 coding

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I need feedback on HCC coding. Is it easier than straight ICD-9 coding? Is HCC coding more time consuming than straight ICD-9 coding? Is there somewhere I could get a list of the HCC codes?


Thanks,
Tammy
 
Hi Tammy, From what I understand, HCC coding is about being as specific as possible when choosing ICD-9 codes (as we should be anyway but sometimes charges aren't reviewed before going out) because the HCC ranking assigned to the codes is a severity ranking. That also means the providers have to be as specific as they can about the diagnoses they see the patient for. CMS has information on their website (CMS Home>Medicare>Medicare Advantage -Rates & Statistics>Risk Adjustment) and there are some videos and other information on www.hccblog.com.
Pam, CPC, CPC-P
 
Tammy,

HCC coding you are only capturing the most severe dx's. There are only only 3,000 some icd-9 codes that have an hcc for them. You code it, look up the hcc that matches the code. If you don't see the code in the hcc manual, then the dx does not fall under an hcc, therefore you don't code it. This is for regular hcc coding. (Now they have RX hcc's which is different.):eek:
 
I would still code applicable codes even if they didn't have an HCC value so it tells the complete story of why the patient was in. You definitely need to make sure that you do code ones that have an HCC value. Providers need to be educated to document all problems that come into play with a particular visit so those HCC codes can be used.
 
my job is working with HCC's. It is about coding as specific as possible.

HCC's ( Hiererchial condition categories) were designed to assign scores to health carriers members' based on their degree of sickness.
I'm not sure if I can get into the specifics of it - the nitty gritty - but know that CMS using the HCC model makes for a more accurate prediction of health care/medical costs.

One should always code to the highest level of specificty anyway, and always code on the claim all the conditions a patient was treated for in an encounter. If a patient comes in for a sore knee but they also review the blood sugars with the PCP because they have diabetes, it is very appropriate to code for BOTH the knee issue and the DM - provided, that is, that it is documented in the chart.

Remember the golden rule : if it's not documented, it didn't happen!!!
 
HCC Coding

I have used the following websites to research on HCC coding. I just finished a couple of projects dealing with HCC coding. I did audits for various Doctors and found some useful tools on these sites.
Hope you find them helpful as well....:rolleyes:
 
HCC coding

Would you please explain me what is exactly HCC coding.And the difference between part I and part II.
 
Hi
To anyone who does HCC auditing:
What is the criteria you look for when billing for COPD? Do you require additional test or do you just go with the physicians documentation?

Also what requirement do you require for Hypoxemia? Do you require additional test or do you just go with the physicians documentation?

Thanks for your help.
 
With HCC coding/Medicare Risk Adjustment, your capturing those conditions that are Chronic. There are several HCC Caregories that certain diagnosis fall under. As far as the Coding Guidelines that your taught as a Coder pretty much doesn't apply to HCC coding most of the time. You will disagree with the rules alot, but you can find out more on CMS website. It is about choosing the Most severe level of a Hiearchy group. This may sound confusing, but you can learn more on the websites supplied in previous responses. Hope this was helpful!!
 
Hcc

the best place CMS...it's their ball and the payors use it to calculate cost associated with risk.

Have fun!
 
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Hcc

I disagree with keke74 that HCC coding "As far as the Coding Guidelines that your taught as a Coder pretty much doesn't apply to HCC coding most of the time." That is absolutely not true. The HCC model actually specifically refers to the CDC's ICD-9 coding guidelines as the rules to go by when coding for HCC's. I think more accurate is the fact that most coding eduation is geared for CPT coding and so there are not a lot of coders out there with a good clinical understanding of disease processes. It IS true that CMS requires more than just a doctor stating "COPD" in the assessment when the patient is actually in for an ingrown toenail and there was no assessment of the condition. That scenario will very likely not stand up to a RADV audit because CMS requires that you submit the best medical record to support that diagnosis, so what you are looking for in a medical record to support an HCC for RADV audit purposes is a record where the condition is clearly assessed and addressed. For example, an assessment that says "CHF, stable" is much better than just plain old "CHF".

Regarding the HCC model, some in this thread have stated that it only includes chronic and the most severe diseases. That is not entirely true, either. Some of the conditions included in the model are status conditions, like s/p BKA or artificial openings (i.e. colostomy, tracheostomy, etc.). Certain fractures and conditions like respiratory failure are part of the model, but may or may not be chronic in nature. Another piece of misinformation I have heard is that there are absolutely no V or E-codes in the model. Again, not true.

I think all of this is just proof that we need to get some really good HCC coding training out there. This branch of coding is only going to grow with the newly-passed health care reform legislation....
 
Serhaug is correct

let me see if I can copy and paste my excel sheet here for HCC/RX codes:

hmm...sorry tried to find it again on CMS and I am just too tired, it's a zipped file

if you want the SPREADSHEET with the HCC/RX 2010 / 2011 www.hccblog.com has a comprehensive wall on its log for conveying the most up to date info out there. Some of the postings have the Excel HCC Sheet for 2010 and 2011 plus many other related information to get one started. I realize that posted that anyone can email me for this Excel sheet. As of now (July) I can no longer comply with what I said about emailing me for the HCC sheet. Due to an enormous new contract I have landed, I must devote all my time to this project to get this under my wing.

My suggestion at this point would be:

www.hccblog.com the excel sheets are included in the bottom of the posts on the wall, have to read and dig
www.cms.gov type in Risk Adjustment HCC in "search" Tab

There may be HCC vendors on the AAPC site. I have never looked for any, but there are a lot of vendors. Check with AAPC "Approved Vendors" as a suggestion, if the company isn't an approved vendor for your membership, you may be wasting your $$ and time with vendors or associations who aren't credited.

I want to thank all of those who have emailed me for the HCC excel sheet, especially the doctors. It was a pleasure to offer this inormation.

Best Regards
 
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HCC is a different animal

All of the auditing tools are geared around supporting CPT level of service.

I work for an IPA in Southern Calif. with 150 primary care doctors in independant practices. Trying to educate these physicians to defend their diagnosis is a bit of a nightmare, they are all over the map. All of the literature you find simply states "documentation must support the diagnosis". This is a challenge, but I am up for the fight.
 
Hcc

In laymans terms, it is just making sure you report the appropriate icd-9 code to the insurance carrier, which receives additional funding for a select group of codes (hcc)

there are 2 parts, the second is for medication allowances.

if you search "hcc coding tool" or "medicare risk adjustment coding tool" you should be able to download one. I know that Humana and Universal HealthCare have them available on the website.

Basically, if the patient has the appropriate codes, a practitioner should see the patient and record the diagnosis every 6 months. So, if a diabetic patient is seen, you want to make sure you capture that diagnosis. More importantly, if the diabetic patient has diabetic nephropathy, they receive more funding.

It is not a new coding system. It is just a pre-chosen select group of diagnosis codes that provide additional money. In all reality, the patient should be seen every six months and each diagnosis addressed. But, some practitionoers have been lazy and only reported some of their diagnosis codes. Because of this the reimbursement to insurance companies have been changed from a straight across the board capitation to for a lack of better words "based on complexity" of the patient.

It does not change E/M coding or what you already know. it is just a reporting system. Insurance companies are aggressively working on this so they dont lose any money!

Hope it makes more sense. Just search for the coding tool on line, you will see the groups of codes. (it's basically the group that costs more: cancer, diabetes + complications, heart diseases, congestive heart failure) Relax... it's simple!
 
HCC Information

I was able to find an explanation and a coding tool quickly.


this website has everything you need:

https://www.univhc.com/providers.asp

on the page, you will see Medicare Risk Adjustment Model (HCC) and view #1-6


"The Centers for Medicare and Medicaid Services (CMS) have implemented a new risk adjustment payment system, called the Hierarchical Condition Category (HCC) payment model. The goal of the CMS-HCC Medicare risk adjustment is to pay Medicare Advantage (MA) and Prescription Drug Plans (PDPs) accurately and fairly by adjusting payment for enrollees based on demographics and health status.

The payment model relies on clinical coding (ICD-9-CM codes) gathered by providers and submitted by the health plans to CMS. HCC's lump 3,100 diagnoses from the ICD-9 system into about 70 diagnostic groups. For your convenience, Universal has developed an ICD-9 Coding Tool that groups diagnoses by CMS-HCC category, which is available on our website.

Appropriate reimbursement to the plan depends on complete and accurate diagnosis reporting. It is more important than ever that Providers update their documenting and coding skills, and improve on coding accuracy. Please ensure that the diagnoses submitted to the plan are fully supported by the member medical record, signature compliant and specified up to the fifth digit.

Important points to remember:
Member health status is calculated by CMS for each calendar year.

All diagnoses vanish on December 31. Chronic conditions must be re-evaluated, documented and billed to the Plan every year.

Patients must be seen by a PCP annually (preferably every six months). Members that have not been seen have no diagnoses.

All new patients must be established with their PCP within 60 days of being assigned an order for CMS to collect accurate member diagnoses. A monthly membership list is available for PCPs to download under the “Provider Login” menu on Universal's website, www.univhc.com

Be sure to report the claims and encounter information in a timely manner, generally within 30 days of the date of service. Universal Health Care is contracted with Emdeon (formerly WebMD) to facilitate EDI claims submission. Our provider number is 50528.

Providers are required to alert the Plan of any erroneous data submitted and follow the Plan's procedures for correcting erroneous data.



If you would like to learn more about the new risk adjustment model you can contact Universal Health Care Medicare Risk Adjustment team at (727) 456-2951 or (727) 456-6503."
 
I am currently doing HCC audits ... You must follow the rules of ICD-9 coding when coding chronic conditions. You must also have "MEAT" to capture these chronic conditions... M=Monitor, E=Evaluated, A=Addressed/Assess, T=Treated. If no "MEAT" is found for conditions stated, you cannot capture. Providers must also follow CMS signature guidelines.
 
jepcpc - great information!

feliciathomas - I really like the "MEAT" acronym. For most conditions that is a great way to figure out whether the diagnosis would stand up to RADV audit. However, there are some status conditions like old MI which only need to be present and documented. The old MI may or may not be acutely addressed, but it plays into medical decision making.

I'm glad this forum has gotten so much traffic! It's nice to know we're not alone out here in the HCC coding world :)

BTW - I just created a new social group on this website for HCC coders. I hope you'll all join!

Serine Haugsness, CPC
 
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HCC coders needed in Arizona

Hi, I'm an HCC coder which I know is not a certification for that but predict there will be one soon. I've been working in the risk adjustment field for 2 years and like the challenge. Previous companies I just pulled the information whether there was M.E.A.T or not, now being trained with a new company to validate and I like this method.
Anyone in the Phoenix, AZ there is a NEED for HCC experienced CPC's so if you want more information on the company that's hiring remote coders, email me offline.
 
Thanks so much for the site for the group...I have joined and am passing it onto those on my team at work. Also, I have to agree with an earlier reply of yours that forwarded an explanation of what HCC/Risk Adjustment coding is about and how ill equipped some coders may be for diagnosis coding.

What some coders may not understand is that CMS reimburses the insurers based on the HCC risk score of a patient which is derived from those medical diagnsoses that are submitted to them. However, insurers reimburse providers on a fee for service/procedure coding system. Differing coding systems can cause problems in equalizing what goes out to what comes in for a patient.

I think a good way to instruct providers is to remind them that they need to establish the medical necessity for a "procedure" and they do so through diagnosis coding. This may necessitate recognition and evaluation of chronic conditions to assure the overall wellbeing of the member. With that in mind, once documented it should be considered for coding.:)
 
$11.00 a hour in southern new mexico

For a newly certified coder is 11.00 an hour a little low for a rual clinic?
 
11.00 an hour?

Is 11.00 a hour for a newly certified cpc a little low for southern New mexico in a rual health clinic?
 
HCC Coding

Hi Tammy,

HCC Coding is not more time consuming but you are extracting all codes in the progress notes and not just HCC codes. The important thing is that the documentation guidelines for HCC Risk adjustment is present so that there are no problems during a Risk Adjustment Data Validation (RADV) Audit. You can find the HCC tables on CMS website, search for HCC Risk Adjustment. There are different payment tables and keep in mind the DOS year vs. payment years.

Hope this is helpful
 
I did HCC auditing for 4 years and it was the easiest job I ever had. NO CPT to worry about and only 3500 diagnosis codes of those you work with a at tops about 50 of them most commonly.
 
HCC Education for Physicians

Hey Coders, do any of you know of some resourceful websites, etc...on where I can gather some information regarding the "points" when educating MDs on HCC....I know CMS has great info, but was wanting some other sources..

Thanks
 
Hey Coders, do any of you know of some resourceful websites, etc...on where I can gather some information regarding the "points" when educating MDs on HCC....I know CMS has great info, but was wanting some other sources..

Thanks

What sort of points are you looking for? I do Risk Adjustment Auditing for a small payer and I get a lot of my educational info from Ingenix (now called Optum Insight).
 
how hard is HCC to learn

how hard is the HCC coding to learn where can I find some really good stuff about it
 
Hcc

I think we should get trained properly, I just applied for a job that only has HCC coding, and I really want that job, but I don't understand HCC coding and I need a quick review.




I disagree with keke74 that HCC coding "As far as the Coding Guidelines that your taught as a Coder pretty much doesn't apply to HCC coding most of the time." That is absolutely not true. The HCC model actually specifically refers to the CDC's ICD-9 coding guidelines as the rules to go by when coding for HCC's. I think more accurate is the fact that most coding eduation is geared for CPT coding and so there are not a lot of coders out there with a good clinical understanding of disease processes. It IS true that CMS requires more than just a doctor stating "COPD" in the assessment when the patient is actually in for an ingrown toenail and there was no assessment of the condition. That scenario will very likely not stand up to a RADV audit because CMS requires that you submit the best medical record to support that diagnosis, so what you are looking for in a medical record to support an HCC for RADV audit purposes is a record where the condition is clearly assessed and addressed. For example, an assessment that says "CHF, stable" is much better than just plain old "CHF".

Regarding the HCC model, some in this thread have stated that it only includes chronic and the most severe diseases. That is not entirely true, either. Some of the conditions included in the model are status conditions, like s/p BKA or artificial openings (i.e. colostomy, tracheostomy, etc.). Certain fractures and conditions like respiratory failure are part of the model, but may or may not be chronic in nature. Another piece of misinformation I have heard is that there are absolutely no V or E-codes in the model. Again, not true.

I think all of this is just proof that we need to get some really good HCC coding training out there. This branch of coding is only going to grow with the newly-passed health care reform legislation....
 
Depending on the company you work for doing HCC coding you probably will be coding wrong if you use codes other than the ones that are HCC. When coding HCC you only want to use dx codes that map to a HCC or RxHCC. Some companies have it already implemented or you have to use an encoder type of HCC lookup to tell you.

HCC coding is more difficult for old timer coders, you feel like your under coding and you have to find/investigate support from labs, medications, a/p throughout that one and only DOS for the dx(s) during that visit. You have to make sure the Name, DOS, Signature/Date is correct or you may not even have to code it if some of that above info is not even on the document.

You may have to get with others but, you'll just have to make up your own list.

Email me if you have any questions..I'm currently on two projects doing HCC, one just coding the other as an auditor.

Thanks,

Katie Williams, CPC, HIT
 
Demetriary, I am not in Phoenix but if this is a remote position does it matter? I have 10+ years experience in CPT/ICD9 coding and understand what HCC coding is. Would love to give it a try. Can I apply?

Kathy KIng CPC-H (previously CPC)
 
Hiya Pam,
Update on your site posting cuz I followed your breadcrumb trail and didn't find the full HHC codes. I did locate them in a .pdf file at this link via CMS. https://www.cms.gov/site-search/search-results.html?q=Hierarchial Health Codes

>>>For Tammy:
After using the formula illustrated in the .pdf the following can be followed:
The full CATEGORY list is found on pages 241-258 (Appendix A) Table A-1; Descriptive Statistics on Prospective Diagnoses on pages 259-280 Table A-2; Table A-3 on pages 281-293 lists Medicare's Concurrent Sample Statistics by all Diagnosis Diagnostic Groups (DXG)

Of course the http://www.hccblog.com/category/hcc-codes/ provides a list of the codes too; albeit not at intense (detailed) as the CMS .pdf file. Along with the last update: http://www.hccblog.com/wp-content/uploads/2011/02/Advance2012.pdf thanks to Matt Yuill MD, CPC for providing the data.
 
Hiya Pam,
Update on your site posting cuz I followed your breadcrumb trail and didn't find the full HHC codes. I did locate them in a .pdf file at this link via CMS. https://www.cms.gov/site-search/search-results.html?q=Hierarchial Health Codes

>>>For Tammy:
After using the formula illustrated in the .pdf the following can be followed:
The full CATEGORY list is found on pages 241-258 (Appendix A) Table A-1; Descriptive Statistics on Prospective Diagnoses on pages 259-280 Table A-2; Table A-3 on pages 281-293 lists Medicare's Concurrent Sample Statistics by all Diagnosis Diagnostic Groups (DXG)

Of course the http://www.hccblog.com/category/hcc-codes/ provides a list of the codes too; albeit not at intense (detailed) as the CMS .pdf file. Along with the last update: http://www.hccblog.com/wp-content/uploads/2011/02/Advance2012.pdf thanks to Matt Yuill MD, CPC for providing the data.


Thank you!!!!:D
 
I need feedback on HCC coding. Is it easier than straight ICD-9 coding? Is HCC coding more time consuming than straight ICD-9 coding? Is there somewhere I could get a list of the HCC codes?


Thanks,
Tammy
yes, go to cms gov and ask for medicare risk adjustment payment system
 
Hi
To anyone who does HCC auditing:
What is the criteria you look for when billing for COPD? Do you require additional test or do you just go with the physicians documentation?

Also what requirement do you require for Hypoxemia? Do you require additional test or do you just go with the physicians documentation?

Thanks for your help.

There are 2 main types of COPD-496 is a broad term: 1. emphysema- 492.8 is slow progression of lung tissue. You loose the ability to expand and contract 2. Chronic Bronchitis- 491.9 - long-term chronic inflammation.
COPD also includes chronic asthmatic bronchitis or chronic bronchitis with asthma.
There is no cure for COPD.
COPD and associated conditiions are 490-496. Documentation shoould fully describe paticular condition. COPD can be coded from Past medical hx as well as current exacerbation of related conditions. (AHA Coding clinic, 2nd quarter 1990, pg 20;3rd quarter 1997 pg 9; icd-9-cm clinic guidelines sec 1.c.8.b.1, sec 1.c.8.a.4)

Hypoxia / hypoxemia 799.02 deficiency of oxygen in tissues and blood, There are many causes.hypoxia is not inherent with COPD. When both are documented together, code both.
Hypoxia/hypoxemia cannot be coded from past medical hx. (AHA coding clinic, 3rd quarter 2009 pg 20 and 2nd quarter 2006 pg 25)

No tests needed- can't take HCC from labs, xrays) must have e/m progress encounter documentation. SGC
 
COPD, hypoxia, hypoxemia

COPD 496 is a broad term which includes chronic asthmatic bronchitis and chronic bronchitis with asthma. There are 2 main types: 1. emphysema 492.8 a slow progression and 2. chronic bronchitis 491.9 long term chronic inflammation. No cure for COPD.
Documentation is to be taken from an E/M encounter progress note or consultation. Labs and xrays are not sufficient.
COPD can be coded from past medical hx. Hypoxia/hypoxemia cannot come from PMH.
Documentation should fully describe the particular condition.
ICD-9-cm Coding guidelines sec 1.C.8.b.1; Sec 1.C.8.a.4 and AHA Coding clinics; 3rd quarter 1997, pg 9; 2nd quarter 1990, pg 20;
Hypoxia- 799.02 deficiency of oxygen to tissue and blood. hypoxia has many causes. It is not inherent with COPD- code both conditions.(3rd quarter 2009, pg 20) 2nd quartewr 2006, pg 24; hypoxemia is inherent to respiratory failure and is not coded separately.2nd quarter 2006, pg 25. HCC coding is more specific. SGC
 
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Answers for you

Hi
To anyone who does HCC auditing:
What is the criteria you look for when billing for COPD? Do you require additional test or do you just go with the physicians documentation?

Also what requirement do you require for Hypoxemia? Do you require additional test or do you just go with the physicians documentation?

Thanks for your help.

Hi I have been doing HCC coding for 2yrs. To code COPD you simply would make sure the pt was truely assessed for COPD such as its listed in HPI, ROS, exam. You should also look for a med to tie it to COPD most providers use ADVAIR, and most importantly if the provider dx in final assessment w/a plan going forward. For HYPOXEMIA you need all the above and documentation that the pt is on O2 the final assessment dx and O2 status is what I look for with hypoxemia. Hopes this help..:)
 
Hi, I'm currently working on a radv audit and some of the coders preferred to valided some of the hcc from a hospital discharge summary versus the pcp progress notes...the pcp is does states patient hcc conditions on the assestment...any thoughts
 
Hi Patty,

You can use them from a discharge summary as long as it meets all the other requirements (name, signature etc). Let me know if you need anything else.

Dwlinda
 
HCC Education

I have been coding for 20+ years and specifically Medicare Risk Adjustment/HCC's for about 3 years now, and I was wondering if anyone has heard of any training, or certifications that might be coming up? Any other education, training sites that might be helpful? I am comfortable and confident in my work, I just haven't seen anything out there for further education. The CMS website is a nightmare, and HCC University is pretty good. Any other information would be helpful! Thanks
 
HCC coding is different than straight ICD-9 coding. If you are coding for HCC capture, you look for only the codes of chronic conditions and they must be on the HCC list with an HCC value assigned...otherwise you don't code it, unless specifically instructed to code ALL diagnoses.y

HCC are mainly used by Medicare Advantage carriers...they get higher reimbursement for patients with more chronic conditions, because they are sicker than someone with only one or no chronic conditions.

I personally LOVE coding HCC!
 
Me, too, Jess! I would also like to know of any HCC job openings! (My contract ended a few weeks ago...)
 
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