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Solutions In Billing 3

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Cheryl Macias

This document discusses hierarchical condition categories (HCCs) which CMS uses to risk adjust Medicare Advantage plan payments based on beneficiaries' medical conditions and costs. It provides steps for medical practices to accurately capture beneficiaries' HCCs through documentation and coding to ensure proper risk adjustment payments from CMS. Key steps include monitoring conditions, testing results, treatments, coding to the highest level of specificity for chronic and acute conditions, and auditing charts to identify any missing HCCs. Accurately following ICD-10 coding guidelines and submitting all relevant diagnosis codes can maximize a practice's risk adjustment revenue from CMS.

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Hierarchical Condition Category By Cheryl A Macias, MHA/Inf, CPC 1
Hierarchical Condition Category Did you know? That currently, CMS uses the CMShierarchical condition category (CMS HCC) model to risk adjust MA payments. This model uses beneficiaries demographic characteristics and medical conditions collected into hierarchical condition categories (HCCs) to predict their costliness Physician groups, along with the MA plans with which they work, stand to collectively lose significant dollars in revenue if they don't quickly learn how to adapt to the new environment. 2
Purpose of Risk Adjustment Risk Adjustments allows CMS to: Pay plans for the risk of beneficiaries enrolled Replaces average amount for Medicare beneficiaries CMS increases the accuracy of payments (health status & demographics) Medicare Managed Care Manual Chapter 7 Risk Adjustment (Rev. 118,09-14-14) Statutory & Regulations Authority Medicare Advantage Plan Part A & B Title XVIII of Social Security Act Subpart G 42 CFR 則 422.304 cms.gov 3
CMS Requirements Yearly Audit for Risk Assessment Conditions Increase in number of Chart pulled for Audits Review encounters spanning One Year Reimbursement is based on supporting documentation within the Medical Record Not because patient/member has a Chronic Condition 4
Steps to Capture HCCs Add some M.E.A.T. in your charting Monitoring-signs, symptoms, disease progression, disease regression Evaluating-test results, medication effectiveness, response to treatment Assessing/Addressing-ordering tests, discussion, review records, counseling Treating-medications, therapies, other modalities Stating [history of means the patient no longer has that conditions] 5
Steps to Capture to HCCs Accurate documentation & coding Offers the practice the ability to gain correct-Risk Adjustment Dollars Captured by the Providers documentation Address all chronic conditions at least annually Code all illness addressed during Face-to-Face visit Code to the highest level of specificity Patients with Ostomy or Amputation Ensure your provider addresses the status during the office visit This allows the Diagnosis to be coded 6
Steps to Capture HCCs ICD-10 CM- Updated Annually (October) Increases correct coding In-house Chart Reviews Creates an opportunity for: In-service training One-on-one training Guide Tools Appeals -Coder review Additional diagnostic codes Positive impact on HCC score 7
Steps to Capture HCCs Electronic Claim Submission Initiate discussion with your Electronic Data Interchange Vendor Receive reports on rejected items Validate maximum number of diagnosis transmitted To receive accurate Reimbursement Validate your claim systems storage capability (diagnosis codes) 損 To capture and send all ANSI837- claim format supports your HIPAA Compliance Question is this process capturing all relevant clinical information 損 Providers/EDI Vendors most times map to legacy transaction the original nine Dx codes and could possibly omitting ten and beyond- 8
Steps to Capture HCCs Research New Products Track diagnosis data for terminated patients Revenue can be recaptured From members who initially were on your monthly eligibility report , but may no longer appear since eligibility has ended. (lost revenue-worth while focus) Audit- for unprocessed data (backlog) New Patients Could have assigned HCCs from prior Health Plan Incorporate plan on to maintain (as appropriate) moving forward as this will increase continuity of care and comprehensive data collection 9
ICD-10 Examples for HCCs Vascular Disease (HCC-108) Manifestations of PVD including: ulcers, gangrene, claudication, cellulitis, & amputation status Artificial Openings for Feeding/Elimination (HCC-188) Surgically created ostomy Assign only complication code-attention to: adjustments or repositioning of catheter, closure, reforming, &/or removal/replacement of catheter 10
ICD-10 Examples for HCCs Morbid Obesity (HCC-22) Is becoming a growing public concern Overweight, obese, morbid obesity- must be obtained from providers documentation and must include BMI, which can be coded from dietitian referral &/or counseling. 11
Questions cherylmacias@hotmail.com 910-617-6495 12

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Solutions In Billing 3

  • 1. Hierarchical Condition Category By Cheryl A Macias, MHA/Inf, CPC 1
  • 2. Hierarchical Condition Category Did you know? That currently, CMS uses the CMShierarchical condition category (CMS HCC) model to risk adjust MA payments. This model uses beneficiaries demographic characteristics and medical conditions collected into hierarchical condition categories (HCCs) to predict their costliness Physician groups, along with the MA plans with which they work, stand to collectively lose significant dollars in revenue if they don't quickly learn how to adapt to the new environment. 2
  • 3. Purpose of Risk Adjustment Risk Adjustments allows CMS to: Pay plans for the risk of beneficiaries enrolled Replaces average amount for Medicare beneficiaries CMS increases the accuracy of payments (health status & demographics) Medicare Managed Care Manual Chapter 7 Risk Adjustment (Rev. 118,09-14-14) Statutory & Regulations Authority Medicare Advantage Plan Part A & B Title XVIII of Social Security Act Subpart G 42 CFR 則 422.304 cms.gov 3
  • 4. CMS Requirements Yearly Audit for Risk Assessment Conditions Increase in number of Chart pulled for Audits Review encounters spanning One Year Reimbursement is based on supporting documentation within the Medical Record Not because patient/member has a Chronic Condition 4
  • 5. Steps to Capture HCCs Add some M.E.A.T. in your charting Monitoring-signs, symptoms, disease progression, disease regression Evaluating-test results, medication effectiveness, response to treatment Assessing/Addressing-ordering tests, discussion, review records, counseling Treating-medications, therapies, other modalities Stating [history of means the patient no longer has that conditions] 5
  • 6. Steps to Capture to HCCs Accurate documentation & coding Offers the practice the ability to gain correct-Risk Adjustment Dollars Captured by the Providers documentation Address all chronic conditions at least annually Code all illness addressed during Face-to-Face visit Code to the highest level of specificity Patients with Ostomy or Amputation Ensure your provider addresses the status during the office visit This allows the Diagnosis to be coded 6
  • 7. Steps to Capture HCCs ICD-10 CM- Updated Annually (October) Increases correct coding In-house Chart Reviews Creates an opportunity for: In-service training One-on-one training Guide Tools Appeals -Coder review Additional diagnostic codes Positive impact on HCC score 7
  • 8. Steps to Capture HCCs Electronic Claim Submission Initiate discussion with your Electronic Data Interchange Vendor Receive reports on rejected items Validate maximum number of diagnosis transmitted To receive accurate Reimbursement Validate your claim systems storage capability (diagnosis codes) 損 To capture and send all ANSI837- claim format supports your HIPAA Compliance Question is this process capturing all relevant clinical information 損 Providers/EDI Vendors most times map to legacy transaction the original nine Dx codes and could possibly omitting ten and beyond- 8
  • 9. Steps to Capture HCCs Research New Products Track diagnosis data for terminated patients Revenue can be recaptured From members who initially were on your monthly eligibility report , but may no longer appear since eligibility has ended. (lost revenue-worth while focus) Audit- for unprocessed data (backlog) New Patients Could have assigned HCCs from prior Health Plan Incorporate plan on to maintain (as appropriate) moving forward as this will increase continuity of care and comprehensive data collection 9
  • 10. ICD-10 Examples for HCCs Vascular Disease (HCC-108) Manifestations of PVD including: ulcers, gangrene, claudication, cellulitis, & amputation status Artificial Openings for Feeding/Elimination (HCC-188) Surgically created ostomy Assign only complication code-attention to: adjustments or repositioning of catheter, closure, reforming, &/or removal/replacement of catheter 10
  • 11. ICD-10 Examples for HCCs Morbid Obesity (HCC-22) Is becoming a growing public concern Overweight, obese, morbid obesity- must be obtained from providers documentation and must include BMI, which can be coded from dietitian referral &/or counseling. 11