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HCCs: Easy as 1, 2, 3 (the culture of MEAT)

JustCoding News: Outpatient, March 19, 2014

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If you started humming the Jackson 5 song "ABC" after reading the headline, that’s a great way to get you in a good mood, but it won’t take you all the way to the finish line when it comes to Hierarchical Condition Category (HCC) coding.
 
Medicare implemented Risk Adjustment HCC code policies in 2004 in order to adjust capitation payments to private healthcare plans. HCCs are based mainly on the health expenditure risk profiles of the Medicare Advantage (MA) plan members. The CMS Risk Adjustment Model also measures the disease burden that includes HCCs, which correlate to ICD-9-CM diagnosis codes.
 
The HCC model used for MA patients categorizes ICD-9-CM diagnosis codes into disease groups that are similar both clinically and financially. For example, ICD-9-CM code 356.9 (unspecified idiopathic peripheral neuropathy) is one of dozens of neuropathy codes to correlate to HCC 071. A hierarchy is created so that patients are coded for the most severe manifestation among related diseases.
 
CMS wipes the slate clean every January 1, so plans must start with a blank slate annually and capture all chronic conditions/HCC codes from providers in order to receive CMS reimbursement. CMS uses diagnosis data submitted from the previous year to establish capitation payments to the MA plan.
 
 
How HCCs affect a MA plan
The CMS model is cumulative, which means that a patient can have multiple HCC categories assigned to them to indicate multiple chronic conditions. Some categories supersede other categories, which comprise the hierarchy within the categories.
 
MA plans use ICD-9-CM and HCC codes as the primary indicators of each member’s health status, as they are directly linked to a member’s individual health risk profile with the plan.
 
MA plans must focus on education to providers as an ongoing initiative in order to capture accurate and complete diagnostic profiles on a provider’s panel.
 
The best way for an MA plan to do so is to employ certified coders to conduct field visits to review charts and identify documentation deficiencies with plan providers, with the goal being to report any existing chronic conditions that may have gone unreported to the plan.
 
As of 2014, 3,166 diagnoses qualify as HCCs, compared to 3,519 in 2013. These collapse into 79 HCC codes for 2014, nine more than in 2013.
 
HCC challenges
MA plans can use various methodologies to accurately capture HCC codes from providers. One is to rely on the provider’s documented data from each patient encounter and ensure that the provider submits ongoing claims for every patient encounter, regardless of capitation status.
 
MA plans have found this to be a monumental challenge because oftentimes a provider’s documentation lacks the MEAT to support reported HCC codes, or no HCC codes are reported.
 
Make MEAT well-done, not rare
MA plans look to network providers to document accurately and submit HCC codes with claims for patient encounters as part of the agreement for providing services to a plan’s members.
 
In order for providers to document accurately, they need to have a thorough understanding of what I call the culture of MEAT (keep humming to the Jackson 5, you’re going to need them to help you follow along).
 
In order to properly assign HCC codes to a claim, the provider must accurately and sufficiently document in a patient’s medical record all chronic disease processes and manifestations that are both active and/or have a relevant history.
 
Applying the culture of MEAT to HCC logic and making sure it is in the documentation is the most effective way to ensure HCC coding accuracy.
 
First, let’s define MEAT:
  • Monitor—signs, symptoms, disease progression, disease regression
  • Evaluate—test results, medication effectiveness, response to treatment
  • Assess/Address—ordering tests, discussion, review records, counseling
  • Treat—medications, therapies, other modalities
 
Whether you are a coder for a provider in an MA plan network or not, providers are required to document allconditions evaluated during every face-to-face visit. Each progress/subjective, objective, assessment, and plan (SOAP) note must include key indicators: history of present illness (HPI), physical exam, and the overall medical decision-making process.
 
Every diagnosis reported as an active chronic condition must be documented with an assessment and plan of care, reflecting that the provider is applying the concept of MEAT.
 
Simply listing every diagnosis in the medical record does not support a reported HCC code and is unacceptable. It will not stand up to validation in the event of a risk adjustment data validation (RADV) audit.
 
The road to success starts and ends with MEAT
 
A variety of downfalls beset providers and MA plans when confronted with a RADV audit. Everyone should remember is that when the provider follows the MEAT guidelines the documentation is basically audit-proof.
 
The best way to do this is by understanding the top 10 ways providers can fail to meet RADV audits. The following is a composite list of what every provider and plan’s review for compliance with CMS risk adjustment guidelines should include.
 
Top 10 fails in documentation:
 
1.      Failing to capture HCCs at least once every 12 months.
2.      Failure to ensure the medical record contains a legible signature with credential. For example, determine whether such as the electronic health record was unauthenticated (not electronically signed).
3.      Failure to ensure the diagnosis codes being billed and the actual medical record documentation match.
4.      Failure to document according to the M.E.A.T. principles. Diagnoses need to be monitored, evaluated, assessed/addressed, and treated.
5.      Failing to annually document status V codes and chronic conditions.
6.      Failing to use a linking statement or document a causal relationship for manifestation codes.
7.      Failing to add any diagnosed HCCs or RxHCCs (prescription drug HCCs) to both the chronic problem list and the acute assessment.
8.      Failing to evaluate each of the HCCs/RxHCCs on a semiannual basis for updates.
9.      Failing to review all specialist documentation related to cardiology, master discharge summaries, radiology, specialty correspondence, pulmonary, echocardiograms, and x-rays, laboratory results, and previous encounters.
10. Failing to submit more than the standard four ICD-9-CM codes.
 
Remember that risk adjustment is an expanding arena for coding professionals and providers alike.
 
The key to successful MA relationships is remembering that at the end of the day, providing timely and accurate documentation and submitting HCC codes allows the plans to receive proper reimbursement from CMS, which in turn allows the plans to provide better benefits to members and improve premiums per member per month (PMPM) to providers.
 
 
Editor’s note: Holly J. Cassano, CPC, is CEO of ACCUCODE Consulting, LLC, of Leesburg, Fla. You can read her weekly blog at http://tacticalminc.com/blog, follow her on Twitter @hollycassano/tacticalminc/welltrackmd, or email her at hcassano@tacticalmanagement.com.



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