HCC/RA Basics From ICD 10 to Documentation Requirements

Going back in time…

To the year 1893… a man named Jacques Bertillon, who was the Chief of

Statistical Services in Paris developed a classification system to track causes of

death. The system was called the Bertillon Classification of Causes of Death,

named after the originator.

At the time, committee members wanted to revise it every 10 years and did so

until finally, in 1945 when diplomats met to form the United Nations, they also

implemented the World Health Organization and the WHO was born.

In 1948, the WHO accepted responsibility for the International Classification

system, which at the time, only included causes of death and mortality. Over

the years though, morbidities were integrated into the classification system

because of the research into how morbidities determined so many patient

outcomes.

The “reformation” of 2007

The WHO began what they called, a “reformation” in 2007 to bring health care

[worldwide] into the 21st century and they are continuing to move forward and

are currently working on ICD 11.

This is not expected to make it to the US market for years to come. (Hopefully,

after I retire).

If you would like a great website to learn more about the ICD 10, disease

pathophysiology and how to effectively use the ICD 10 you can check out:

http://apps.who.int/classifications/apps/icd/icd10training/ICD-10%20training/Start/index.html

It will walk you through each chapter in the ICD 10 and tell you about specific

diseases, as well as help you learn more about how to use the ICD 10 to code

more accurately.

Other countries use the ICD 10 for statistical purposes, the United States

uses it for statistical and for reimbursement purposes.

Because CMS has structured future reimbursement around quality of care

and quality measures of chronic conditions for risk, the ICD guidelines

require us to code all comorbid conditions that exist and are currently

being treated or managed.

But, because we use an international classification system, we have to be

very careful in knowing about certain codes and the guidelines for those

codes because they may be classified differently in other countries than

they are here in the US because of the disease process.

For example:

Valve disease:

There are specific guidelines for coding heart valve disease for people living

in the US verses people living in foreign countries or developing countries that

do not have the same availability to medicines.

The guidelines include documentation requirements that specifically state if

the patient has a history of rheumatic fever to establish the code for a

rheumatic valve problem.

Rheumatic fever is a systemic immune process that is a sequela of

streptococcal infection of the pharynx. Strep throat left untreated can

develop into rheumatic fever.

In the US, most of our valve problems originate from atherosclerosis.

Now let’s talk about RA -

CMS states,

“ Risk scores measure individual beneficiaries’ relative risk –

and risk scores are used to adjust payments for

each beneficiary’s anticipated expenditure”

In layman’s terms:

Risk Adjustment is a methodology that is used by third party payers, such as

Medicare or Medicare Advantage Plans to adjust reimbursement based on a

beneficiary or members risk score.

How does it work?

Risk scores are calculated from a member’s demographics, diagnoses and

other data retrieved from claims and encounters.

The claims are submitted from the providers to the MA Plans who in turn

submit them to Medicare.

Medicare puts the received data into an algorithm or equation used to

determine the overall risk score for each member.

Each chronic condition that qualifies on an HCC-RA model is assigned a value.

These chronic condition “values” are totaled for each member and that is

how they receive their final risk score.

The risk scores are used to determine payments that will provide the member

with appropriate care for his/her chronic conditions in the following year.

Payment Models

There are currently 4 payment models in use:

CMS-HCC Hierarchical Chronic Condition Model used by Medicare

specifically for Medicare recipients only.

HHS-HCC Commercial Model using different demographics and

qualifiers/equations than the CMS-HCC model.

CDPS Medicaid model for children, adults and specific individuals.

ESRD End Stage Renal Disease Model

There is also a RxHCC – Prescription drug model that helps to calculate and

predetermine CC’s based on drug use compliance.

CMS –HCC Model This is considered a prospective model because it uses retrospective audits to

predict a cost analysis of what the member will need in the following year.

• CMS-HCC categorizes ICD 10 codes into disease groups.

• Each HCC category includes diagnosis codes that are related clinically and have similar cost implications.

• The most recent HCC version includes 8,800 ICD 10 codes that map to 79 HCC categories.

• CMS-HCC model is solely diagnosis-driven.

• Procedures DO NOT affect the grouping, which is why when you are doing risk adjustment coding, those codes are not taken into consideration for the CPT level of service, unless that’s the reason for the patient seeing the provider.

• HCC’s are cumulative in nature. Meaning, HCC DX are extrapolated from many

encounters for a beneficiary for a specific time period (e.g.year) that

contribute to a total risk score for the member.

• Even though HCC’s reflect hierarchies among related disease categories,

unrelated categories accumulate for the patient, as well, for a total score.

• So, the patient can have more than one HCC category assigned to him or her.

• The “hierarchy” comes into play when one or more than one DX is within the

same category and one “trumps” the other out.

For example, DM with no complications is lower in “weight” or risk score than

DM with a complication.

The risk is higher when there is a complication and the DM is already being

calculated within the DM complication category, so the lower risk score is

“trumped out” and only the higher risk score is used that contains both

categories.

The patient’s RAF score includes the demographic information, as well as all

applicable chronic condition diagnosis codes, which together contribute to a

member’s risk score.

So, CMS-HCC’s have two components: the hierarchy AND the condition category.

• Hierarchies are imposed among related chronic conditions.

• After the hierarchy occurs, then a chronic condition becomes an HCC.

HCC-17 DM with acute complications

HCC-18 DM with complications

HCC-19 DM with no complications

HHS-HCC It uses concurrent DX to develop the risk score for the member during the

current year.

• This is the risk model used by commercial insurance payers.

• This model uses it’s grouping of chronic conditions to represent member’s

health status and benefit plan selection. All DX/conditions must be

documented within the current year for annual risk adjustment.

• The calculations are set up differently, the approach is different and the

methodology is different from the CMS-HCC model.

• This is a “metal plan” difference – the levels are set up as Gold, Silver,

Bronze, etc. with ratings variations.

• There is a metal combination for each age group, as well as methodology.

(i.e. adult, child, infant) and the metal combinations include Platinum, Gold,

Silver, Bronze, catastrophic.

CMS-HCC and HHS-HCC

CMS-HCC

Medicare Advantage Plans RA

model

Funded by CMS

Prospective Data

Providers document all HCC’s their

patients have in a given year to

substantiate a base year health

profile for each patient that

predicts costs in the following year

79 CMS-HCC Categories

HHS- HCC

Commercial RA Model – the population includes adult, children and infants

Funded by members and supplemented by the government

Concurrent data used – the risk score is calculated based on the DX from the same payment year.

Providers must identify/document all HCC conditions their patients have in that year.

Risk scores are calculated for each member, but applied in aggregate and the funds are redistributed between issuers within the state, when necessary for that payment year.

Getting into the MEAT of things- Documentation Requirements

Chronic condition coding is a requirement, it’s not an “elective”.

CMS is making the move to Value-Based reimbursement in hopes it will promote

and provide quality of care to it’s members.

Right now, these value-based programs reward providers with incentive payments

for the quality of care they provide to patients.

Quality of care extends further than the provider-patient care experience.

Quality of care includes the documentation the provider supplies so that other

providers may view and care for the patient appropriately, but also to the

coding, billing and financial care we provide to patients.

Documentation requirements include:

Must be a face-to-face visit – can be IP or OP.

Labs, radiology, diagnostic testing, etc. do not count as face-to-face visits and

cannot be used in risk adjustment coding.

In order to meet the challenge of accurate and complete documentation, the

acronym MEAT was established to help the coder more accurately determine if a

chronic condition is available in the documentation to code.

There is another acronym TAMPER that is

acceptable as well.

M E A T When reviewing the note, you are looking to see if the provider met any of the

conditions below when trying to determine if you should code a chronic condition

Did the provider -

M Monitor: Signs, symptoms, disease progression and disease

regression

E Evaluate: Medication effectiveness, response to, lack of response,

asking the patient how they are doing or how they feel they are doing in response to one of their chronic conditions; even though the provider may not be managing that specific chronic condition.

A Assess/Address: The provider’s assessment of the condition, did the

provider order any tests, discuss the condition with the patient, review of records, and/or counseling.

T Treatment: Did the provider prescribe any meds, therapies, referrals,

other modalities.

T A M P E R

T Treatment

A Assessment

M Monitor/Medicate

P Plan

E Evaluate

R Referral

Documentation Examples: Looking at it with MEAT-

CHF: “Symptoms well controlled with Lasix and ACE inhibitor. Continue

meds”.

Using the MEAT acronym – The provider Monitored that the symptoms are well

controlled and Evaluated the symptoms are being

controlled by the current med regime.

Major Depression: “Patient continues with feelings of hopelessness and

anhedonia despite Zoloft 50 mg daily. Will increase

dose to 100 mg daily and monitor.

Provider assessed how the patient is doing with

symptoms, treated with an increase in meds.

Atrial Fibrillation: “Controlled with Warfarin, will continue to monitor INR.

Or it could be stated – INR being monitored in Coumadin

clinic. Monitoring weekly.

DM : “stable on meds, no complications noted, order labs,

refilled prescriptions for lancets and Metformin.

Prostate CA: no change in condition, being seen by Dr. Watts in

Oncology, on watchful waiting.

Code the Note:

Patient: Sally Jones DOB 12/01/38 DOS 05/03/17

Patient is a 72 year old female with UTI like symptoms. Patient c/o fatigue, low energy and poor appetite. Patient is status post MI 18 months ago. Patient appears frail and with mild malnutrition. Has lost 23 pounds in the last 4 months. Patient has been complaining of pain with urination, weakness, and has had dry, itchy skin for the past several months. U/A done today shows WBC’s, leukocyte esterase, and microalbuminuria. Serum creatinine is 1.5.

PMH: Type II DM, CKD secondary to DM, history of BKA-skin intact at stump, no erythema. History of MI. Previous UTI 4 months ago with a serum creatinine of 1.6. Lab results at that time revealed stage 2 CKD.

A/P:

DM – Metformin 500 mg, b.i.d

Bactrim for UTI

Malnutrition (documented as Mild in HPI) Ensure b.i.d. and nutrition consult

RTC in 6 weeks. Referral made to Dr. Smith (Nephrologist) for CKD.

Note electronically signed by John Jacob Jinglehimerschmidt, MD 05/04/17

Coding:

UTI –: N39.0 (Does not map to an HCC) – reason for the visit

to provider today

DM w/CKD: E11.22

CKD–Stage 2: N18.2

Oral DM Med: Z79.84

Malnutrition-Mild: E44.1

BKA, unspec: Z89.519

Old MI: I25.2 ( Maps to the RxHCC)

NOTE: If I were coding this in “real life”, I would take a moment to review

previous documentation to code a more specific code for the unspec BKA.

Final Thoughts:

It is acceptable to include a “history of” as a chronic condition, if it affects the

current treatment or plan, or is supported as a current dx.

For example: A history of melanoma when ordering a biopsy for suspicious skin

lesions.

But, there is a caveat that should not be overlooked; stating “history of” is often

interpreted by CMS and Recovery Audit Contractors (RAC) to mean the patient no

longer has that condition. This can lead to a denial of payment.

This can be averted, if the condition really does exist and is still being treated,

as well as PROPERLY DOCUMENTED.

Using the M.E.A.T. criteria helps ensure that documentation satisfactorily meets CMS requirements for supported diagnoses.

Any condition addressed or considered by the provider as relevant to treatment at the time of the encounter should be documented, preferably, in the Assessment and Plan.

Each diagnosis listed should be properly documented with evaluation and/or treatment. (You may see the notation in another location within the note.)

A list of diagnoses is not acceptable evidence that the diagnosis affected patient care.

Following these documentation principles will ensure accurate documentation, improve patient care delivery and data integrity by validating diagnosis codes while reducing risk to the organization.

RA Risk Adjustment

HCC Hierarchical Chronic Conditions

RAF Risk Adjustment Factor

RADV Risk Adjustment Data Validation

RAPS Risk Adjustment Processing System

RAS Risk Adjustment System

RxHCC Prescription Drug Hierarchical

Condition Category

DHHS/HHS Department of Health & Human Svcs

EDI Electronic Data Interchange

ESRD End stage renal disease

FERAS Front End Risk Adjustment System

HMO Health Maintenance Organization

IVC Initial Validation Contractor

MA Medicare Advantage

MCO Managed Care Organization

MMR Monthly Membership Report

List of RA/HCC Acronyms