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HCC coding - ICD-9 coding

  1. #11
    Medical Coding Books
    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.

  2. Default
    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!!

  3. #13
    Smile Hcc
    the best place CMS...it's their ball and the payors use it to calculate cost associated with risk.

    Have fun!
    Last edited by KellyLR; 07-14-2010 at 01:21 PM. Reason: Removed bad connection

  4. #14
    St. Louis West, MO
    Default 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....

  5. #15
    Default 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
    Last edited by KellyLR; 07-14-2010 at 01:19 PM. Reason: Revision

  6. Cool 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.

  7. #17
    Wink 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!

  8. #18
    Default HCC Information
    I was able to find an explanation and a coding tool quickly.

    this website has everything you need:


    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 ‚ÄúProvider Login‚ÄĚ 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."

  9. #19
    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.
    Felicia A. Thomas, CPC
    Atlanta, GA

  10. #20
    St. Louis West, MO
    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
    Last edited by serhaug; 05-11-2010 at 10:54 AM. Reason: Had a bright idea and wanted to add to previous post!

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