Risk Adjustment 101

Welcome to the first of a four-part article series on Risk Adjustment and Hierarchical Condition Category (HCC) coding. The series will focus on the 4 A's of HCC coding:

• Accurate documentation
• Appropriate coding
• Awareness of all chronic conditions (even if they’re being treated by a specialist)
• Always open communication among physicians
  
  

What is a HCC and how do you support it with clinical documentation?

Hierarchical Condition Category (HCC) is groupings of clinically similar diagnoses in each risk adjustment model. Conditions are categorized hierarchically, and the highest severity takes precedence over other conditions in a hierarchy. Each HCC is assigned a relative factor which is used to produce risk scores for Medicare beneficiaries based on the data submitted in the data collection period. There are currently 79 HCC categories. And, while all diagnosis codes are mapped to a condition category, not all condition categories are included in the model used in payment.

How to avoid common HCC coding errors

A common error that occurs during the coding process is coding an acute condition as a chronic condition. For example, coding a cerebrovascular accident (VCA) as an active condition. Once a patient is discharged from the hospital, it’s no longer an active condition, but rather part of the history—regardless of where the patient is discharged to. This coding error can occur by working off the shortlist when coding in the electronic medical record (EMR). How often do you review the shortlist and how often is it updated?

In this example the appropriate codes are:

• Acute CVA ICD 10 code -163.00-163.09 Cerebral Infarction
• History of CVA ICD 10 code -Z86.73
• Sequela should be coded if noted

To support a HCC, the clinical documentation in the patient’s health record must support the presence of the chronic condition. This acronym can help code risk adjustment accurately:

M—Monitoring

E—Evaluation

A—Assessment

T—Treatment

R—Referral

If you have any specific questions regarding HCC coding please email HealthTeam Advantage’s Risk Adjustment team at RiskAdjustment@healthteamadvantage.com or fill out our short form on Capturing an HCC.