1. Gail Woytek, RHIA, CCS, CRC
Medicare Part C Risk Adjustment Coding Hierarchical Condition Categories
NOV29th
2016
Gail Woytek, RHIA, CCS, CRC
Rochester Regional Health Information Management Association

2. objectives
Explain how and why Medicare Part C and Risk Advantage Plans were created
Define principles of Hierarchical Condition Category (HCC) Coding
Describe difference between Medicare Advantage and PACE HCCs
Demonstrate coding scenarios with compliant application of codes
Present CMS tables for use

3. Medicare Part C Medicare Part C is Medicare Advantage (MA) model
Otherwise known as MA plan
Developed to expand options under private insurance plans
Differs from traditional fee-for-service models
i.e., Medicare Part A (inpatient services) and Medicare Part B (outpatient and physician services)
Combines Part A and Part B into one product
Company offering health care plan is paid monthly premium per beneficiary rather than fee for each service

4. History of Risk Adjustment
Balanced Budget Act of 1997 mandated implementation of Risk Adjustment (RA) to increase payment accuracy
Many refinements in the RA methodology over the years
By 2007, payments to MA plans were 100% at CMS-HCC rate
Not only are diagnosis codes used for payment methodology, but also other demographics
Beneficiary’s age
Gender
Race
Socioeconomic status
Place of service codes
Patient conditions
i.e., ESRD patient or in hospice

5. What is Risk Adjustment?
Patient’s chronic conditions
Clinical acuity and diagnostic profile of those enrolled in plans
Ensures payment
Promotes fair payments to MA plans and rewards efficiency and excellent care
Predictive payment methodology

6. Predictive Modeling
Analytical review of previously submitted data to CMS to identify possible future diagnoses that should be used for risk adjustment purposes
Health care plans may use analytics to look at this data and determine that a patient may have a condition that had not been documented thoroughly by the physician and not captured
Condition could have been incorrectly coded either by someone not qualified, or a diagnosis code could have been selected from a pick list in an EMR

7. Predictive Modeling, cont.
A retrospective review of the medical records of patients that have been targeted as having a suspected condition can be performed by a certified coder
The diagnosis can be validated and submitted for payment. Reflects the health of the patient
Predict future costs
Being able to predict patient’s future needs can help disease management and improve quality of care

8. Risk Adjustment Models
Chronic Illness and Disability Payment System Medicaid (CDPS)
Hierarchical Condition Categories Medicare
HHS-HCC Commercial Insurance
Prescription based model RX HCC
Models can be reviewed three basic ways
Retrospectively
Concurrently
Prospectively

9. Who is being Risk Adjusted?
Participants eligible for Medicare
Dual eligible special needs patients that are entitled to medical assistance under a Medicaid state plan
End Stage Renal Disease patient
Program for All Inclusive Care for the Elderly (PACE)

10. PACE Growing rapidly in United States
Programs provide comprehensive medical and social services to those that meet certain eligibility requirements
Over 55 years of age
Sufficiently frail to be considered for nursing home care yet are community dwelling

11. PACE, cont.
Their risk scores are based on their demographic factors, diagnosis codes and frailty factor
Frailty factors are based on the number of limitations in activities of daily living (ADLs)
PACE and ESRD patients fall into the same HCCs which differ slightly from the MA HCCs

12. hccs
An HCC is determined by taking a patient’s ICD-diagnoses codes and filters them into Diagnosis Groups, then into Condition Categories where hierarchies or related disease processes are used to determine a HCC numeric code
Not all codes fall in to an HCC, typically the codes that determine an HCC are costly to manage; chronic or serious conditions

13. hccs, cont. Not all codes fall in to an HCC
Some codes map to an HCC for MA but not PACE
Payments differ between MA HCCs and PACE HCCs
HCCs change each year, recent changes were made to accommodate ICD-10, make sure you are familiar the annual changes
RX HCCs use dx codes to predict Part D spending

14. Change Examples
In 2014 the MA HCC reimbursement rate had a blended model, with each version paying at a different rate. This year there is only one rate
In 2014, MA and PACE plans were paid for peripheral neuropathy, this year only PACE plans will be reimbursed for that diagnosis
The HCCs for diabetes underwent a major change for payment year 2015 also. Most of the manifestations do not fall in to a higher level HCC

15. MA vs. Pace HCCs Patient profile 88 years old Male
Senile dementia, COPD, DM II, Right Hemiplegia due to old CVA, CKD III, S/P L AKA
Code
MA HCC
PACE HCC
250.00 19
294.20
112 RX RX
438.21
103
496
111
585.3
138
V49.76
189

16. Payment Values
The lower the HCC number the higher the acuity and therefore a higher payment
CMS provides payment only for the most severe manifestation of a disease process
Not all codes used for HCCs
Codes tell the story

17. “Trump” Codes
Examples of codes that trump others from the same “family” or disease groups:
Ca of the colon code HCC 11 with mets to the brain HCC 8. Drop the code for ca of the colon. HCC 8 has the more severe risk
Vascular insufficiency of the colon code HCC 108 will be trumped by atherosclerosis of the artery of the extremity with gangrene HCC 106

18. Hierarchy Example ICD-9 Code ICD-9 Description
MA Model 22 (for 2015 DOS)
PACE Model 22 (for 2015 DOS)
1983
Sec Mal Neo Brain/Spine 8
1984
Sec Malig Neo Nerve Nec
1985
Secondary Malig Neo Bone
1539
Malignant Neo Colon Nos 11
1540
Mal Neo Rectosigmoid Jct
1541
Malignant Neopl Rectum
1542
Malig Neopl Anal Canal
1543
Malignant Neo Anus Nos

19. Hierarchy Example, cont.
ICD-9 Code
ICD-9 Description
MA Model 22 (for 2015 DOS)
PACE Model 22 (for 2015 DOS)
5848
Ac Renal Failure Nec
135
5849
Acute Renal Failure Nos
5851
Chro Kidney Dis Stage I
139
5852
Chro Kidney Dis Stage Ii
5853
Chr Kidney Dis Stage Iii
138
5854
Chr Kidney Dis Stage Iv
137
5855
Chron Kidney Dis Stage V
136
5856
End Stage Renal Disease
5859
Chronic Kidney Dis Nos
586
Renal Failure Nos
140

20. Additive Example Patient has multiple sclerosis, angina, and diabetes
Code
HCC
340 77
413.9 88
250.00 19

21. RX HCC ICD-9 Code ICD-9 Description 2015 RX HCC 2400 Simple Goiter
42 : Thyroid Disorders
2409
Goiter Nos
2410
Nontox Uninodular Goiter
2411
Nontox Multinodul Goiter
2419
Nontox Nodul Goiter Nos
24200
Tox Dif Goiter No Crisis
2720
Pure Hypercholesterolem
45 : Disorders of Lipoid Metabolism
2721
Pure Hyperglyceridemia
2722
Mixed Hyperlipidemia
2723
Hyperchylomicronemia
2724
Hyperlipidemia Nec/Nos
2725
Lipoprotein Deficiencies
2728
Lipoid Metabol Dis Nec
2729
Lipoid Metabol Dis Nos

22. Coding Nuances Not all codes map to an HCC Condition Code HCC
Essential Tremor
333.1
None
Parkinson’s Disease
332.0 78
Accidental Barbiturate OD
E937.0
Suicide by Barbiturates
E950.1 58
Ischemic Cardiomyopathy
414.8
Idiopathic Cardiomyopathy
425.4 85
Not all codes map to an HCC

23. HCC Coding Requirements
Face to Face visit
Acceptable provider
Code only from the narrative of the provider, do not “diagnose” the patient yourself based on diagnostics or drugs prescribed
“History of” diagnoses are not coded, confirm by the documentation whether that condition is currently being treated

24. Hcc coding Requirements, cont.
Use “TAMPER” acronym to ascertain if condition is currently being treated
Treat
Assess
Monitor or Medicate
Plan
Evaluate
Refer

25. HCC CODING Requirements, cont.
Some chronic conditions that need to be addressed annually are
Amputations of the lower limbs, or toes
Paralysis
Sickle cell trait
Multiple Sclerosis
COPD

26. HCC CODING Requirements, cont.
Outpatient coding guidelines are used for the coding of both MA and PACE models
Look up every code!!
No use of suspected, probable, consistent with, rule out
All diagnosis codes must be coded to the highest degree of specificity
Do code the diagnoses that are used for the RX HCCs, for example asthma, hyperlipidemia

27. CMS Documentation Requirements
Must be legible
Must be signed
Approved credentials must be in record
Clear, consistent, complete
Must have a face to face in the payment year
The diagnosis must be substantiated in the documentation

28. Acceptable Providers

29. Acceptable Facilities
Covered Facilities
Hospitals
Short-term (General/Specialty)
Long-term
Rehabilitation
Children’s
Psychiatric
Medical Assistance Facilities/Critical Access Hospitals
Community Mental Health Centers 1
Federally Qualified Health Centers 2/Religious Non-Medical Health Care Institutions
Formerly Christian Science Sanatoria
Rural Health Clinics

30. Non-Acceptable Facilities
Non-Covered Facilities
Free-standing Ambulatory Surgical Centers (ASCs)
Home Health Care
Free-standing Renal Dialysis Facilities

31. Coding Challenges
A very common diagnosis you will see in provider’s record is cancer. Unless the patient is undergoing chemotherapy, radiation therapy or hormonal therapy, it cannot be coded. Just a note in the record stating the patient is being followed by an oncologist does not imply a current cancer diagnosis
Compression fractures must be current to be captured, many MDs continue to document despite the fracture occurring in the past. There must be some sort of treatment, such as pain management

32. Challenges, CONT. Artificial openings.
Morbid obesity and malnutrition.

33. Challenges, CONT.
A pcp may not always document a peripheral vascular disease or peripheral neuropathy, but a podiatrist note will have the elements of documentation that you can use to capture the code
The same goes for some ophthalmology diagnosis codes. Be sure to review all consultant notes to code any significant diagnosis

34. Challenges, CONT.
If a condition is contradicted in different parts of the record do not code it
Some serious conditions due fall in to HCCs such as hip fractures that occurred in that payment year
Be very careful with amputations, most that you will encounter in HCC coding will be past surgical, not traumatic

35. More coding challenges!
Don’t make assumptions regarding drug prescriptions. If a patient is on Lamictal, do not assume they have a seizure disorder, this drug is also used for bipolar disorder. If a patient is on warfarin, do not assume it is for a vascular condition, it could be for a fib, mirtazapine for depression or an appetite stimulant
This is true particularly for RX HCCs, there should be a correlation between the drug that may be on the medication list, aspirin may not necessarily be taken for CAD

36. Physician Queries
If you see documentation in a medical record that indicates a condition is being treated or addressed in some way, but the provider has not specifically written that diagnosis in his assessment, it is appropriate to query that provider in a non leading way to clarify his documentation. This allows for not only accurately identifying the patient’s medical profile, but also results in correct reimbursement the provider

37. Example
The code of has been submitted on a patient, but prescriptions being filled for Plavix have been filled. That patient may have vascular manifestations of diabetes that the provider did not document properly or the record was not coded to the highest degree of specificity
The patient has a PMH of CVA , but no codes for any residual effect. That medical record can be reviewed for a possible hemiplegia as a result of the CVA

38. RADV AUDITS CMS Risk Adjustment Data Validation (RADV) Audits
Purpose is to verify a plan’s risk adjustment payments, assess the quality of the data submitted, and determine the national payment error rate
Both MA plans and PACE programs are targeted annually to submit samples of their documentation
May be financial implications dependent on findings

39. Risk-Free Risk Adjustment Coding
Use official ICD-CM outpatient coding guidelines
Look up every diagnosis code
Do not make assumptions re, do not diagnose the patient yourself
Use all parts of the patient face to face visit; the CC, HPI, PMH, PSH, ROS, PE, Assessment and Treatment Plan, consultant notes, etc to substantiate your code
Code to highest level of specificity
Ensure the note/record meets CMS requirements

40. Chronic conditions that should be addressed once per year
Sickle cell trait
COPD
AAA if seen in PMH with size and no surg hx
Diabetes
Multiple Sclerosis
Organ transplants (not kidney) including stem cell
HIV

41. Tricky diagnoses Dementia: what type? Behavioral disturbance?
Depression: 311 (RX) ?
Diabetes with manifestations: Due to? With?
Morbid obesity: BMI? Stage?
Malnutrition/ cachexia?
Skin ulcers: Venous? Pressure? Stage?

42. references http://www.cms.gov/medicarehealth
radvchecklist.pdf

43. Thank you
Q&A