Prospective HCC Coding

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I am in the process of beginning prospective HCC coding at the organization where I work. I have been researching prospective HCC coding and can't find any specific guidelines. Everything is generalized. What are the specific guidelines that would assist me in creating a workflow for this process? We are thinking about getting software from RCX with a module called Chart Prep. The workflow would be for me to review the problem list or any prior diagnoses the patient has had in three years. Then I would make a list of diagnoses to send to the provider as potential diagnosis to review during the Medicare Wellness. I have not done prospective HCC coding before. I have only been reviewing documentation after the encounter is completed. I want to stay within the guidelines of not leading the provider. How do I accomplish this? What workflow or suggestions do you have in what I can present to the provider and how do I present it prior to the visit?
Hello JTuttle:)
Here are four tips may help you in creating workflow for HCC coding. 1.,Read the full medical record documentation for content, 2nd time review for understanding, 2 Second read highlight the main terms of diagnostic code (chronic acute or malignant). 3.Be careful of doppleganger medical words or integral coding 4.Make notes some where for self incase come across the same situation in coding.
HCC coders must look for details of disease in stages, or levels, or chronic or aligned with the patient comorbidities or complications that develop. Also using the guide MEAT documents of Monitor, Evaluate, Assess and Treat) while abstracting to select the correct diagnostic code as principal dx code. The provider may need help in understand documenting the dx convention codes. They are used to the EHR in selecting dx but we know their documentation is the most important to support HCC. Whereas the HCC coder will ensure correct ICD10 dx are selected in tune to the documentation = HCC values. Medicare assigns each dx code to HCC values associated with risk. Sicker patients have higher HCC values. There are over 9000 dx acute & chronic code assigned to link with 80 HCC and 75 Rx HCC all updated annually by CMS . The diseases that have complications have higher HCC values.

I d break it down for major dx use per type of medical specialty, then their mapped HCC values . A great book to get is Risk Adjustment Documentation & Coding by Sherri Poe. In the back of the book list major HCC values to dx codes (you can find online too). Also in back of this book is a handout on differ medical service for a provider's attention to major points need to document. Always ensure the provider add to notations of patients who have forever ds vs chronic ds, vs combination ds. TOAD=Transplants, Ostomies, Amputations, Dialysis...ensure the provider adds this too if it applies to the patients. Adds to HCC values

Did I help you? I hope so
Take Care
Lady T
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Hi Again JTuttle;)

The 8 vital chronic diseases = AF, DM COPD,Rheum Arthritis, Mutiple Sclerosis, CHF, Parkinsons Ds, HTN,
Top 10 comorbidities= HTN, HLD, Osteoart, CHKD, Anemia, Hypothyroidism, Depression ,COPD, DM, Ischemic Heart Ds all from Medicare patients
List of Forever Ds=Depression, DM, Autism, Sickle Cell, Lupus, Migraines, AIDs-HIV, Intellectually Challenged, Parkinson Ds, Muscle Dystrophy ,ALS, Substance Abuse, Alcoholism, Herpes, Amputations, Paraplegic
A few combination diseases.....HTN+CHF, UTI +B96, DM & manifestations , BMI +Z68% CKD+ HTN Pressure Ulcer L89 + DM, Dementia+Alzhemers
If pt suffers with cardiac or respiratory or gastro conditions if documented and currently smokes add F17 or Z72 or past smoking HO Z87
Some dx codes do not risk adjust such as Anemia, IBS, Down Syndrome, Stroke scores, or signs and symptoms when the definitive dx code is given.
I remember some of this from my past research which I hope you can use. I d put it in handout for the coders and providers or do a presentation.

Lady T:)
Interesting. I have only done retro reviews. Is this a new process for your organization? It sounds like they need a planning session and workflow procedure to be set up. I would also be worried about leading, however if you have an EHR there has to be a way you can automate this process. For example, if the patient has a chronic disease that is never "cured" that disease/problem should always be reported. I know how it goes though, that we see these diagnoses drop off and they are missed.
I don't think simply reviewing the prior records and presenting a list to the provider for review is leading if those were confirmed, documented diagnoses by the provider previously.

Not sure the EHR workflow but it seems it would be a pre-visit review or a workflow/inbasket step to present prior to the upcoming visit. I think a lot of this would need to be set up with administrators/providers to figure out internal policy. The compliance department should be involved as well. Also, if you have a CDI department possibly.

These are just some links I searched, not sure about any of the products, etc.

Prospective Review

A prospective coding review process is intended to help physicians prepare for upcoming patient encounters.
Reviewers—who are often certified risk coders—evaluate the patient’s HCC code history, prescription drugs, hospital records, lab results, and physician notes. They may also leverage access to out-of-network claims, which helps establish a 360° view of available clinical information.
As coders review the medical record, they identify patients with likely HCC conditions whose diagnosis codes have not been captured accurately. Once the HCC opportunity has been identified, the next step is to prepare the physicians to address the condition(s) at the upcoming appointment. This communication is often performed via updates to the EHR problem list or delivered to the physician ahead of the patient’s visit via a morning huddle or similar type of meeting.
The physician must then ensure that the noted conditions are documented and included in the encounter as appropriate. If the physician’s examination of the patient supports the HCC condition, he or she will then document and capture the HCC code(s) during the encounter. Employing staff members, who assist with pre-visit planning, significantly improves the process and reduces the burden put on the physician.
we had a very robust prospective HCC program in our practice.

there is some good advice here, but if you have any specific questions, please feel free to PM me.
This is something our practice is looking into also. I have a vague question on documentation. Do you have to use M.E.A.T or TAMPER to validate the HCC diagnosis or simply listing the condition and using the med list to support this? Ex: COPD

Hi Smithca :)
The provider must document Monitor illness, Evaluate it, Assess how pt coming along ,and Treat it with meds or referral to ancillary test or specialist. Just listing condition and meds is not correct. TAMPER = treatment, assessment, monitor/medicate, plan, evaluate, or referral. TAMPER helps coders address diagnoses in question that are presented in a list or are noted with a “history of” description. If a coder believes a diagnosis is current but it is listed under Active Problems, Ongoing Problems, Chronic Problems, Past Medical History (PMH), etc., the coder should ask, “Did the provider TAMPER with the diagnosis on the DOS?” If the answer is yes, the diagnosis is current. If the answer is no, the diagnosis is not current.
Also sometimes the provider will say pt has history of DM...he is saying pt has current dx whereas if providers gave dates when pt had illness years ago help coders distinguish between current illnesses vs personal history dx block of codes Z87 and Z86. Another example is pt has history of thyroid surgery 4 years ago then as coder know to use dx Z86.3

Well I hope I helped you a little bit.
Lady T(y)