Medical coding

A hot topic in health care today is Hierarchical Condition Categories (HCCs), and there is no better time to consider the value of HCC coding to your home-based primary care program!  HCC coding is the risk adjustment method used by Centers for Medicare and Medicaid Services (CMS) to determine the annual payments for patients in Medicare Advantage plans.  HCC risk adjustment uses predictive modeling to determine the severity of patients’ conditions, health risk, and status to project the cost of health care coverage for that population.  This is how CMS determines cost savings for patients enrolled in Accountable Care Organizations and the Independence at Home Medicare Demonstration, and HCC risk adjustment will also determine into which Practice Risk Group patients will be placed for the new Primary Care First Model.

Correct diagnosis coding is always important, but it is critical for accurate risk adjustment because it drives appropriate reimbursement for provider services in value-based payments.  An easy “best practice” to initiate is to always code to the highest specificity.  Unfortunately, Electronic Health Records (EHRs) complicate this because the search list populated for diagnosis codes frequently brings the unspecified codes to the top of the list. To overcome this challenge, we recommend creating a list of HCC diagnosis “favorites” that will more easily display for selection. Check if your EMR can highlight diagnoses that map to HCC scores.  Partnering with a certified medical coder can assist in ensuring accuracy in the common conditions included as “favorites,” especially for disease combinations such as diabetes with chronic kidney disease. In addition, you can also consider running a diagnosis utilization report to identify your most frequently treated HCC diagnoses and then review and update your problem lists so you can be as specific as possible for patients with those conditions.

Correct coding is essential for accurately predicting future health care costs for patients and ensuring the appropriate reimbursement for providers.

To enhance your understanding of which conditions carry a risk adjustment factor, download our HCC Resource Sheet for Home-Based Primary Care (HBPC) which provides a list of common HBPC diagnoses for HCC scoring.