Wiki HCC documentation vs EM LOS

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codingwithkelly

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I'm just getting started with HCC Risk dx and a question has come up regarding the EM level.

Patient is seen for an acute illness and ONLY the acute illness is documented in the HPI and Exam. In the A/P Provider documents the acute illness and notes patient's DM is under good control with insulin.

Note w/o DM management meets 99213 (Det/EPF/Low), but with the DM and the insulin, MDM bumps the level up to 99214.

I've always coded only conditions addressed in the HPI or found/addressed in the exam, but now with the HCC Risk how does this effect the level?

Thank you,
Kelly
 
HCC is diagnosis coding ONLY.... It has nothing to do with E/M levels. I would pull the dx code that risk adjust to an HCC from the A/P as the final diagnosis. This is because the physician is documenting the patient's current status. I'm not sure what your internal guidelines are for pulling chronic conditions from the HPI and Physical Exam but it's always safe and accurate to pull from the A/P.
 
So, we dont count the HCC dx as part of the MDM?

This is my cunundrum...the HCC diagnosis codes are not addressed anywhere except the MDM. I know to list them last, I just dont know if we are to count them as part of the MDM.

I know the docs are going to say "I addressed them, so I should count them". But then I'm going to tell them the conditions will need to be addressed in the HPI also. If not, they can't count in the MDM. Is this what you are doing?
 
You cant mix them. If your doing straight HCC coding, then you only worry about the supported Dx codes. Dont worry about the MDM and E/M. Thats where a lot of ppl get it confused. I work for a medicare advantage plan and all I code is HCC. I never worry about the Fee-for-service that is documented in the Note. :cool: You also have to take in account as well that no matter if the MD wants to Bill a Level 5, your only Coding HCC so the Money paid to the Health Plan will be based off the Supported Dx's and not the Level of Service.
 
Ah...Ok. I just started with a Medicaid Ins Co that wants me to work with the providers on documenting the patients HCC codes so we can be paid appropriately from the State. So, this may be the problem...the insurance co pays the provider FFS - we should be looking at how we are reimbursing our providers. Some are paid on capitation, but many have moved to FFS...looks like capitation is the key - at least in the articles I'm reading.
 
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