Coding Tip Corner - June 2023

Written by HealthTeam Advantage | Jun 22, 2023 1:10:01 PM

Correctly capturing diagnoses during encounters—particularly with complex patients—is vital for receiving accurate reimbursement.

In 2022, the Centers for Medicare & Medicaid Services (CMS) began relying on encounter data alone for Medicare Advantage (MA) diagnoses. For accurate provider reimbursement, improved capture of all possible Hierarchical Condition Category (HCC) codes is essential.

Part C Risk Adjustment Model revision for calendar year 2024:
CMS finalized proposed changes to the HCC risk adjustment model but will phase this in over three years. CMS will calculate risk scores by blending 67% of the risk scores as calculated under the current 2020 model and 33% of the risk scores as calculated under the updated 2024 model. For 2025, the blend will shift to 33% of risk scores calculated with the 2020 model and 67% calculated with the 2024 model. For 2026, CMS expects 100% of the risk scores to be calculated with the 2024 model. The phase is consistent with how CMS has implemented prior model updates.

Changing HCCs:
The revised model will increase the number of payments HCCs from 86 to 115. This is because of newly created HCCs and the splitting of existing HCCs as a result of moving from ICD-9 to ICD-10. The number of ICD-10 diagnosis codes mapped to an HCC for payment in calendar year 2024 will decrease from 9,797 to 7,770.

Example: HCC 189 Amputation Status, Lower Limb/Amputation Complications has been deleted.

All subsequent amputations: i.e., S88.121S - Partial traumatic amputation at level between knee and ankle, right lower leg, sequela

Please remember that while this HCC will no longer be used for Risk Adjustment in the new version, it still will be used in the blending of Risk Adjustment model versions 2020 and 2024.

These changes will be reviewed in more detail during the year presented through the HealthTeam Concierge Roundtables. Please make sure to attend those meetings. You can also reach out to us at riskadjustment@htanc.com.

As always, while there are many changes taking place, the key to coding remains consistent. Accuracy is key!

Coding Best Practices	Coding Not Best Practices
Code all documented conditions that coexist at the time of the encounter/visit that affect patient care.	Do not code conditions that have resolved unless a status code is available to represent the historical condition.
Code first the reason for the visit, then add chronic conditions (HCCs) that are also addressed in the documentation.	A simple list of problems or diagnoses is not acceptable documentation.
Include ALL conditions affecting patient treatment or management.	A problem list must show evaluation and treatment for each condition that relates to a diagnosis.
Look for documentation using MEAT concepts.
How is provider Monitoring, Evaluating, Assessing, or Treating the condition?	A problem list may be useful to initially gain an overall clinical picture, but conditions that are current must be supported by other documentation.
Ensure that you always use the most specific codes to describe the diagnoses in the documentation.
Use combination codes when appropriate.	Forgetting to recapture a diagnosis code/HCC on an annual basis
Always follow “code also” and “use additional code” notes.	Lack of supporting documentation for a chronic condition
Keeping the reason for the visit current	Failure to update the reason for the visit
Encouraging the patient to discuss life changes	Showing no interest in life-changing experiences

Have a safe and happy Fourth of July, and please use sunscreen! 🌞

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