Hierarchical Condition Category (HCC) Coding and Risk Adjustment
Michael Stearns, MD, CPC, CFPC, is a physician informaticist, certified professional coder (CPC), certified family practice coder (CFPC). He is the CEO and Founder of Apollo HIT, LLC, an Austin-based company that provides consulting services in the areas of healthcare information technology and compliance. His company assists organizations with meeting their documentation, coding, EHR optimization and program goals, including their performance in the Merit-based Incentive Payment System and Alternative Payment Models.
During his career, Dr. Stearns has received several awards for teaching and contributions to patient safety and patient privacy initiatives. He played a central role in the design and development of vocabularies at the National Institutes of Health (NIH) and provided a lead to the development of the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT). He has served in a leadership capacity for two leading EHR vendors and as an advisor to several emerging HIT organizations.
He is a cofounder and lecturer at the University of Texas at Austin Health Information Technology Certificate Program, a nationally recognized model for HIT workforce development. He has been invited to testify in Washington, D.C. before federally sponsored HIT policy and standards organizations on five separate occasions. He served as the founding board president of the Texas eHealth Alliance, an organization that provides stakeholder input related to health information technology policy matters to state legislators. He is also an accomplished author and lecturer on a range of health care quality, health information technology, coding/compliance and quality-based performance initiatives.
He can be reached at: firstname.lastname@example.org
HCC codes were primarily associated with Medicare Advantage programs in the past, however, they are now being much more frequently encountered by clinicians who are involved in MSSP ACOs and those eligible for the MIPS. More than 9000 ICD 10 codes map to 79 HCC codes in this risk adjustment model. Awareness of specific HCC relevant diagnoses and their impact on the risk-adjusted score can have marked significance towards future reimbursement in capitated models, ACOs and performance in the MIPS. This discussion will explain how HCC codes are used to determine risk-adjusted scores in the Medicare Advantage program, ACOs, and the MIPS. It will also explore potential pitfalls associated with documentation deficiencies and the potential for over coding, with its consequent penalties.
A growing number of CMS programs are using HCC codes to determine reimbursement amounts based on the risk associated with the patient’s demographics and underlying conditions. Programs that use HCC codes to determine a risk-adjusted factor include Medicare Advantage, Medicare Shared Savings Program (MSSP) Accountable Care Organizations, the Cost performance category of the Merit-based Incentive Payment System (MIPS), and other initiatives. The majority of clinicians that care for Medicare beneficiaries will be increasingly impacted financially by HCC codes.
- Background of HCC coding
- The HCC Risk Adjustment Model
- How HCC codes are used In the Medicare Advantage Program
- How HCC codes impact ACO performance and potential shared savings and shared losses
- How HCC codes impact MIPS performance
- Compliance requirements associated with potential fraud waste and abuse in the risk adjustment model
- The importance of accurate documentation in the clinical record to support reported ICD-10-codes
Course Level - Intermediate to advanced
Who Should Attend
Physicians, clinicians, CDI professionals, coding professionals, administrators, compliance officers, revenue cycle professionals
Why Should Attend
Physicians and other clinicians who care for Medicare beneficiaries need to increase their awareness of HCC codes to avoid significant revenue loss. Administrators, health information management professionals, and coding professionals also play a significant role in ensuring that clinicians are adequately trained and that relevant medical diagnoses are not going undocumented or under-documented. There is a significant potential for fraud waste and abuse associated with HCC coding, as healthcare systems are allowed to retrospectively review records and identify missing codes with risk adjustment factor significance. Clinicians and administrators need to be aware of these risks.