HCC Coding

The Risk Adjustment Program

DATE: January 2021 PRESENTED BY: Monique Vanderhoof, RHIT, CCA, CPC, CRC
 What is Risk Adjustment?
• Began as part of The Balanced Budget Act in 1997
• Payments to health plans and provider groups
based on a patient’s health status and
demographics.
• CMS and HHS pay more per month for patients
with a higher disease burden
– This is to offset the cost of providing care

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 HCC Basics
• HCC stands for Hierarchical Condition Category.

• An HCC is assigned to a patient based on the ICD- 10-CM

codes submitted on claims throughout the calendar year.

• Over 9,600 diagnoses fall into different “chronic condition

buckets.”

• HCC’s are additive – meaning they are added together to

create the overall risk score for a patient.

• The risk score associated with HCC’s resets every year (i.e.,
January 1)

• Not all diagnoses are HCC’s but most chronic conditions are
(i.e., DM, CHF, AFIB, etc.).

• CMS and some insurers pay more per month for patients
with a higher disease burden.

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 Impact of Annual Capture
FEW Chronic Conditions SOME Chronic Conditions ALL Chronic Conditions
Coded Coded Coded
76 year old female 0.437 76 year old female 0.437 76 year old female 0.437
Medicaid eligible 0.151 Medicaid eligible 0.151 Medicaid eligible 0.151
PVD (I73.9, HCC 108) 0.298 PVD (I73.9, HCC 108) 0.298 PVD (I73.9, HCC 108) 0.298

DM not coded (no HCC) 0.0 DM (E11.9, HCC 19) 0.118 DM with PVD (E11.51, HCC 0.368
18)
CHF not coded (no HCC) 0.0 CHF not coded (no HCC) 0.0 CHF (I50.9, HCC 85) 0.323
No interaction 0.0 No interaction 0.0 Interaction (DM + CHF) 0.182

Raw RAF Score 0.886 Raw RAF Score 1.004 Raw RAF Score 1.759
Little Reimbursement More Reimbursement Max Reimbursement

We are somewhere in-between We want to be

here here!

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 What is an HCC?
• HCCs are added to create a risk score for a
patient from ALL Face-to-Face visits with an
“acceptable provider type”
– Inpatient, Outpatient, Observation, ED, Clinic

• Greater than 40% of HCCs are not CCs or MCCs

– Complete coding of all documented diagnoses
is important!

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 Risk Adjustment Scoring
Each HCC category has a series of ICD-10-CM codes that
map to it.
Example :

Provider assessment:
Pt with Type 2 diabetes with CKD, stage 4

Coding:
Type 2 diabetes with CKD – E11.22 = HCC 18
CKD, stage 4 – N18.4 = HCC 137

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 HCC Model List

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 HCC Hierarchy (Trumping)
• Trumping means to excel, surpass or supersede
in rank, value or importance
• In HCC risk score calculation the most significant
conditions trump others in the same category
HCC Category HCC Description Risk Score Value
17 Diabetes with Acute Complications 0.368

18 Diabetes with Chronic Complication 0.368

19 Diabetes without Complications 0.118

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 Why are they Important?
• Risk Adjustment Factor (RAF) scores help drive
payments for risk based contracts, and
government based programs.

• Patient complexity scores drive quality

assessments

• Some here at OHSU:

– OHSU Health
– Moda Beacon
– Cambia Bridgespan
– Medicare Advantage
– CPC+
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– Oncology Care Model (OCM)
– Bundled Payments
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 Why OHSU?
Audits demonstrated that OHSU was consistently under
performing on patient complexity measures (i.e., RAF Scores).
This negatively impacts quality ratings and reimbursement for our
clinics.
There are also concerns with clarity of documentation in the
ambulatory setting, which can affect patient care.
Goals:
1. Improve patient care via more accurate representation of active
medical problems
2. Integrate documentation efforts with growing care
management functionalities
3. Receive appropriate reimbursement from year to year for
relative costs of care
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Current Work:
All work now inclusive of coders and providers at Hillsboro and Adventist

1. Monthly strategy
Health meetings
System including OHSU,
AH, HMC
Collaboration

HCC Clinical
Ambulatory
Documentation EHR Tools
CDI
Improvement and Data
Specialists
Analytics

Monique 1. HCC audit tools based on

Vanderhoof, billing & claims data, CE
HCC Program
1 coder Manager
position
2. Epic tools: BPA SmartSets,
vacant due Diagnosis Calculators, etc.
to budget
4 HCC Population
restrictions Education 3. Webi reports
Certified Provider Health
Coders Educator 4. HCC BPA refinement

1. Prebill WQ’s 1. Direct Patient Scheduling for

(PC and Oncology) 1. Monthly/Quarterly
provider meetings PC for HMC and OHSU
2. Provider query for 2. Panel/Care Coordinator
documentation 2. 1:1 provider intensives
Standard Work
clarification
3. Coder centric education 3. Incentives
3. Problem list updates
4. Specialty engagement 4. HCC impact for VBCs &
MSSP
 HCC Team
Topic: Summary:

Goal of • Accurately reflect the quality of care we provide

workgroup/team: • Enable OHSU Health to compete effectively in value-based marketplace

Current • Refining epic tools to aid providers in real time (BPAs & Diagnoses calculators)
work/projects • Pre-bill claim review by HCC coders to confirm accurate coding/documentation
underway: • Webi reports and Epic registries to understand baseline and opportunity
• Ongoing provider and coder education
• Pre-bill WQ in Oncology
• Plans to work with Neurology, Pre-op, Pediatrics

Looking Ahead: • Advancing partnership with Adventist and Hillsboro Medical Center
• Understanding the impact of HCCs for VBCs such as the IDS and MSSP
• Defining HCC goals and targets for FY21

Barriers: • Provider/clinic buy-in difficult to obtain without aligned incentives

• Dedicated staff to support MWVs and outreach
• Problem list is the foundation of many epic driven tools

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Moving forward
Projects Underway:

• Refining epic tools to aid providers in real time (BPAs & Diagnoses
calculators/Preference Lists)
• Addition and refinement of HHS HCCs
• Defining HCC priorities and aligning across OHSU Health System
• Problem List update by HCC coders
• Working to better understand HCC impact across system

• Ongoing work with:

• neurology(OHSU and HMC), pre-op(OHSU), cardiology(HMC), oncology(OHSU and
HMC), endocrinology(HMC)

• Plans to expand work to Pediatrics early 2021

Current Barriers:
• Provider/clinic buy-in difficult to obtain without aligned incentives

• Dedicated staff to support MWVs and outreach

• Problem list is the foundation of many epic driven tools
• Payer/Epic reporting variances
• Resource variation across OHSU, HMC, and AH
• AH Epic system differences
Diagnosis Calculator
How can we use tools we already have to help providers code better?

New diagnoses preference lists were created to identify the correct

diagnosis codes when documenting a visit. The tools assist providers to meet
ICD-10 coding requirements and accurately capture patient’s complexity
scores.

Old Version New Version

 HCC Best Practice Alert

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Epic Workbench Report
 Pre-bill Review Work Queue

• HCC coding team is reviewing all primary care charges from

risk based payers. This ensures all ICD-10 codes are accurate
based on documentation before they are sent to insurance
companies.

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 Outcomes……

CMS average score = 1.0

Patient population
represented here = 582

• Overall scores increased 13% between 2017 and 2018, and

another 7% in 2019

• What if these lives were in a capitated arrangement?

– The 18-19 increase would equate to $419,056 ($59.00 PMPM
rate using 2021 CMS rate book)
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 Focus on
Correct Coding &
Documentation
 Education
• Provider meetings (group education) quarterly
• 1:1 provider education
• Monthly coder education

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 Correct coding & documentation
In order to capture HCC’s appropriately providers must:
• Code all documented conditions that exist at the time of
the encounter and require or affect patient care,
treatment or management
• Accurately document all chronic diseases, manifestations,
and status codes at least once each year
• Document and code chronic conditions being managed
by specialist
• Document using M.E.A.T. concepts

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 M.E.A.T.
Documentation must prove that the patient’s
condition(s) were:
Monitored
Evaluated
Addressed
Treated
• Only one element of M.E.A.T is required. Two
or three are better!
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 M.E.A.T.

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 Correct coding & documentation
• A simple list of problems or diagnoses is not
acceptable documentation
– For RADV purposes a problems list must show
evaluation and treatment for each condition that
relates to a diagnosis code
*per Risk Adjustment for Medicare Advantage Organizations Participant Guide

• A problem list may be useful to initially gain an

overall clinical picture, but conditions that are
current must be supported by other documentation

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 Correct coding & documentation
Official ICD-10-CM guidelines state that accurate
coding cannot be achieved without clear, consistent,
complete documentation in the medical record.

Guidelines further instruct to code all documented

conditions that exist at the time of the encounter, and
require or affect patient care, treatment or
management
-

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Frequently overlooked HCC’s
• CHF • Transplant Status
• Angina • Dialysis Status
• Atrial Fibrillation • Malnutrition/Obesity
• COPD • Neutropenia,
• Compression Fx thrombocytopenia, etc.
• Seizure Disorder • Bowel Obstruction
• Psychoses • Diabetes and
• Rheumatoid Arthritis complications
• Polymyalgia • Metastases
Rheumatica (PMR) • Ventilator dependence
• History of Amputation
 Questions?
THANK YOU!!!
HCC Program Manager:
Monique Vanderhoof, RHIT, CPC, CCA, CRC
[email protected]

Next session – February 16, 2021

Diagnosis Coding for Wellness Exams
Thank You