Coding can be a tedious and intimidating process, with thousands of codes to choose from that all link back to different categories. There are two types of codes that help you attain your risk adjustment factor (RAF) score: the hierarchical condition categories (HCC) codes and the international classification of diseases (ICD) codes.

For context, there are more than 72,000 ICD-10 codes, and 9,757 ICD-10 codes that map to one of the eighty-six HCC codes within the Centers for Medicare and Medicaid Services (CMS)-HCC Risk Adjustment Model. When you take a look at these numbers, it’s no wonder why more providers and coders are looking for HCC coding assistance when calculating RAF scores.

Having the right coding tool can streamline your coding practices and optimize your patient care. Inferscience offers an array of coding tools, such as the HCC Assistant, which provides you with HCC risk adjustment code suggestions after analyzing your patient’s EHR and health record.

With HCC coding tools, you can access the codes you need in real-time. This tool gives you the shortcuts you need to focus on your practice, instead of combing through thousands of codes for the right ones. In this article, we’ll dive into the purpose of risk adjustment coding, critical principles for coding, and shortcuts to the most-missed HCC opportunity codes.

The Purpose of HCC Risk Adjustment Coding

Risk adjustments allows CMS to make appropriate and accurate payments for enrollees with differences in expected costs. Risk adjustment adjusts bidding and payments based on demographics–such as age, gender, and race–and the health status of an enrollee.

The RAF scoring model aims to predict the future healthcare costs for specific enrollees for CMS health plans based on their current risk factors associated with their population. Using HCC diagnostic groups, providers and insurers can assess the disease information of enrollees.

General HCC Principles

Selecting the correct codes is only one critical step in managing high-risk patients. These tips will help ensure you are getting credit that is accurate to the care and management you provide for your high-risk patients:

• Code the complications as well as the condition, because these typically increase the patient’s risk scores.
• Avoid symptom codes when possible, because they do not result in risk adjustments. Use diagnosis codes instead.
• Report the diagnosis codes for active diagnoses each year, because HCC codes reset annually, no matter how long the patient has had the condition.
• Report secondary diagnoses if you’ve addressed them or they played a role in managing the other condition that prompted your patient’s visit.
• Always provide documentation for your diagnoses, because undocumented diagnoses affect the reimbursement in value-based care and impact your patient’s outcomes.

While billing and reimbursement are important reasons to be diligent about your HCC and ICD codes, these codes also serve as critical documentation that can directly impact your patient’s quality of care.

The Most-Missed HCC Opportunity Codes

Even with diagnoses with higher prevalence in your practice or specialty, ICD-10 diagnosis codes are often missed, which can result in inaccurate RAF scoring. Here are some of the most commonly missed ICD-10 diagnosis codes that are connected to HCC opportunities according to Delaware Valley Accountable Care Organization:

• HCC18: Diabetes with chronic complications – ICD10 codes E11.21, E11.22, E1140, and E11.51
• HCC19: Diabetes without complications – ICD10 code Z79.4
• HCC22: Morbid obesity – ICD codes E66.01 and Z68.41
• HCC23: Other endocrine and metabolic disorders – ICD code E21.0
• HCC40: Rheumatoid arthritis and inflammatory connective tissue disease – ICD code M06.9
• HCC48: Coagulation defects and other specified hematological disorders – ICD codes D68.51 and D69.6
• HCC59: Major depressive, bipolar, and paranoid disorders – ICD codes F32.0 and F32.1
• HCC85: Congestive heart failure – ICD codes I11.0, I27.20, I50.22, and I50.9
• HCC103: Hemiplegia or hemiparesis – ICD code I69.351

There are also HCC codes that are missed due to their lower prevalence in the population, but come with a significant average risk score. For example, pressure ulcers of skin with necrosis through muscles or tendons have an average risk score of 2.253.

When these codes are missed, not only does it make things more complicated for your coders and insurance, but your patient suffers, as well. When diagnoses are missed, your patients run the risk of receiving incomplete care.

Never Miss a Code With HCC Assistant

Inferscience’s software solutions simplify your HCC coding practices. The HCC Assistant allows you to analyze patient data from the electronic health record (EHR) or external sources, and provides HCC coding suggestions in an intuitive, expandable tab.

With the HCC Assistant, you will be able to streamline your HCC coding practices for your Medicare patients and provide optimal care. Contact Inferscience today for your free demo!

References:

https://www.mainlinehealth.org/-/media/files/pdf/basic-content/physicians/mlhpp/resources/dvaco-prms-commonly-missed-and-confusing-hcc-codes.pdf
https://www.hccinstitute.org/app/uploads/2021/09/HCC-Quick-Reference-Guide_210608.pdf?x23823
https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/hierarchical-condition-category.html

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