Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC
Understanding HCC’s —what are HCC’s?
- HCC (Hierarchical Condition Category) is a method of risk stratification used by the Centers for Medicare & Medicaid Services (CMS) to direct level of payment for Medicare Advantage (MA) Plans (Medicare Part C).
- HCCs are also used by CMS to risk stratify populations related to ACA Exchange Plans, and have financial implications in this area as well.
- The HCC system identifies patients with serious and/or chronic illnesses and assigns a risk factor score to each, based upon a combination of demographic details, health conditions as submitted on claims in the prior 12 months, and the cost to treat various illnesses.
- This risk factor score reflects the anticipated risk for a member to utilize services in the future and determines the amount MA Plans are reimbursed by CMS. The higher the overall risk factor scores for an individual, the greater the premium (per member per month) paid to the MA plan.
- The patient’s medical problems are identified through ICD-9 diagnosis codes chosen by providers during face-to-face encounters and submitted on claims. Over 3000 ICD-9 diagnosis codes in the HCC payment model map to approximately 80 HCCs, which are then submitted to CMS for reporting purposes.
Listed below are a few basic diagnosis examples of common HCCs reported within the Medicare population—
- 250.00 Diabetes with no complications
- 496 Chronic Obstructive Pulmonary Disorder
- 492.8 Emphysema
- 427.31 Atrial Fibrillation
- 428.0 Congestive Heart Failure
Good documentation and abiding by CMS guidelines is the key to maximizing reimbursement with the HCC payment model. CMS guidelines state that HCC participants must complete the following:
- All diagnosis codes must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis needs to be coded according to ICD-9 diagnosis guidelines.
- Diagnoses must originate from acceptable data sources such as hospital inpatient and outpatient facilities, and physicians.
- Submit all required ICD-9 diagnosis codes for each beneficiary and submit diagnoses at least once during the reporting period (once per calendar year).
Documentation must be correlated to support the submitted diagnoses. The medical record should support the HCC and also indicate the provider’s assessment and plan for the management of the illness/condition. The diagnoses of the chronic illness/condition should be addressed and appended to encounters minimally on a yearly basis or the provider will not receive credit for the MA’s will have to submit a medical record example on a yearly basis to CMS that best supports the individual’s HCC condition, so proper, thorough documentation is an absolute necessity for appropriate reimbursement.
Included below are a few documentation statement samples that fully support HCC conditions billed:
“Patient presents for shortness of breath that’s further complicated by the patient’s history of COPD”
“Patient has known peripheral vascular disease due to diabetes mellitus”
“Assessment: Hypertensive CKD III, stable, well-controlled, continue with current prescriptions”
Remember—if it’s not documented, then it wasn’t done! Coding to the highest degree of specificity combined with thorough, complete documentation is critical in ensuring success with the HCC coding guidelines.