January-February 2021

Leave No HCC Behind
By Elizabeth S. Goar
For The Record
Vol. 33 No. 1 P. 10

Don’t allow those elusive coding critters to escape your grasp.

Broader adoption of value-based payment models has intensified focus on appropriate hierarchical condition category (HCC) coding paired with risk adjustment to create a more complete picture of a patient’s risk factors and, subsequently, optimize provider costs and quality performance scores.

Proper capture of HCC codes was already complex—some have a risk adjustment factor (RAF) value while others don’t, and some are additive while others have multipliers—but the rapid adoption of telemedicine during the COVID-19 pandemic has added a new wrinkle by eliminating physical exams, the absence of which eliminates some HCC codes from consideration and exposes use of others to greater scrutiny.

“With telemedicine, the physician needs to make sure they are asking the same questions that they are asking when a patient is in person. Many physicians [may] struggle with this as the format of a telemedicine visit is not the same as they are used to with in-person visits,” says Julie Seaman, CCS, CCS-P, senior director of coding, clinical documentation improvement (CDI), and compliance for eCatalyst Health.

The key, as is often the case, is comprehensive supporting documentation.

A Brief HCC History
Originally implemented in 2004 by the Centers for Medicare & Medicaid Services (CMS), HCC coding was created to estimate future health care costs by mapping each HCC to an ICD-10 code. It is used by insurance companies in conjunction with demographic factors to assign patients an RAF score, which can then be used to predict costs. The more chronic conditions a patient has, the higher their expected health care utilization and costs.

The RAF score is used by Medicare to quantify the anticipated costs for each beneficiary. An average patient’s RAF is 1.0. A patient with an RAF of 2.0 is expected to cost twice as much in care than the average patient, while those with an RAF of 0.5 will cost one-half as much. CMS uses this information to adjust capitation payments made to Medicare Advantage plans, which, in 2019, covered 22 million beneficiaries primarily enrolled in HMOs, PPOs, special needs plans, and group plans.

For providers, more accurate HCC coding leads to more appropriate reimbursement levels. For that to occur, however, providers must identify qualifying conditions annually. In some cases, that requires face-to-face visits and/or laboratory tests, all of which must be properly and completely documented in a manner that supports the diagnosis code.

This is where things can get sticky.

“Risk adjustment is a way to forecast future financial needs. When diagnosis codes are omitted, it is difficult to accurately identify the patient population and the medical expense needed for their care,” says Angie Ramos, RHIA, CPHQ, CRC, director of population health CDI with Enjoin. “The impact on quality scores has a similar effect because the encounter does not accurately represent the care provided to the patient.”

Adding to the challenge is COVID-19, which Ramos says will play into both reimbursements and quality because patients are delaying routine care as well as more urgent needs.

“CMS does allow risk adjustment to be captured with telemedicine visits if the same criteria as a face-to-face visit is met and the visit was conducted via audio and video [in] real time synchronously. This might help to offset a portion of the uncaptured diagnoses,” she says.

Documentation Downfalls
According to Seaman, one of the primary documentation challenges centers around manifestation of conditions, which “are definitely some of the harder things that physicians tend to miss.”

For example, a patient with diabetes may not always present with symptoms of retinopathy or other manifestations of the disease, “but if [a physician is] treating the diabetes, they really should be documenting the manifestations and how they are being managed [because] it will impact decision making for that visit,” she says. “Or sometimes they are honestly not treating that condition on that visit, but they still must remember to link how it affects management of the patient at that visit. It’s challenging because if physicians don’t link it, it won’t meet [CMS] guidelines.”

Among the conditions physicians commonly omit that map to HCCs are congestive heart failure, cancers, major depression, morbid obesity, and chronic hypoxic respiratory failure. This is due in part to the subtle nuances involved in their documentation. For example, Enjoin Medical Director Brett B. Senor, CRC, CCDS, MD, notes that a congestive heart failure patient often has a constellation of findings suggestive of heart failure, such as echo, diuretic, and/or beta blocker, but no capture of the condition.

With cancers, “the primary issue is the opposite—overcapture of a historical condition that is no longer being treated,” Senor says, adding that “surveillance following completed treatment does not suffice for capture.”

Most providers do not use the language specificity necessary to trigger an HCC for major depression, Senor says. Nor are most providers aware of a second World Health Organization definition for morbid obesity of a body mass index of 35, or 29.9 when associated with an obesity-related comorbidity.

Senor notes that documentation challenges arise when there is a lack of understanding of how HCC-based risk adjustment impacts physicians, patients, and health systems, which can result in a lack of provider engagement in the process. Also at play is a lack of training regarding diagnosis-specific criteria, as well as “workflow encumbrance by the EMR.

“All too frequently, physicians have lamented the number of clicks necessary to get to the ‘right’ diagnosis,” he says. “They may be unaware of possible shortcuts that might get to the correct diagnosis. [Or] providers are simply trying to work through their patient lists, providing the best care they can in a time-efficient way. Often, documentation suffers as a consequence.”

When documentation suffers, so too does the provider’s quality score and reimbursement, Seaman notes. Quality scores are impacted when documentation doesn’t demonstrate that HCC-mapped conditions are being treated at required intervals, she says.

“As far as reimbursement, that code must be recorded at least once during the year … to get the reimbursement for that level of HCC acuity,” Seaman says. “But again, it goes to the patient not presenting [the condition] at every visit. But if it’s not documented at least once [per year], it will impact reimbursement. They get paid a risk-adjusted reimbursement based on their patient’s aggregated RAF scores [which requires appropriate documentation].”

Fixing the Problem
When it comes to solving the problem of inappropriate or inadequate documentation to support HCC codes, Seaman says the most effective way is to ensure that manifestations are added to the patient’s problem list. This makes it available for the physician to review at every visit.

To reach a broader group of patients, eCatalyst Health offers programs wherein they review cases for missing HCCs. They examine a patient’s data over time to identify any manifestations coded by any physician who has seen the patient. Those data are then used to query physicians and establish pre- or postvisit queries to ensure the information is properly documented.

“The problem list is obviously their best bet on a regular basis,” Seaman says. “But using an outside service can help get to a larger group of patients.”

She notes that it’s also important to ensure that diagnoses from any specialist who sees the patient is added to the problem list. “If a specialist is with an outside physician group that is not in the same medical record system, make sure that, once the [specialist] reports back, that [their] diagnosis makes it to the problem list. It’s an extra step, but it’s important,” Seaman explains.

Ramos concurs that problem lists are a smart target when it comes to improving documentation involving HCC codes. Cleaning them up is a “relatively small task that can have a large impact.

“Oftentimes, diagnosis codes are captured from the problem list or copied from a previous encounter and the documentation does not support the coding [or] MEAT [monitoring, evaluating, assessing, treatment] criteria. This puts the practice in a vulnerable position due to compliance risks,” she says. “On a greater scale, in addition to the traditional inpatient CDI program, we encourage implementing an ambulatory CDI program to help improve clinical reliability and the integrity of health care data. It is also important to establish a physician champion and obtain leadership buy-in for success. Ongoing chart reviews and provider education are the keys to success.”

By identifying the root causes of incorrect coding and documentation practices, a plan of action can be developed to correct them. For example, Ramos notes that Enjoin’s population health mantra consists of analytics, data-driven decisions, integrated physician support, and ongoing operational support. Claims data are analyzed to determine pain points and challenging areas, including low risk scores, areas of low-hanging fruit, and challenges within a specific practice or specialty.

These data are then used for targeted clinical chart reviews. Previsit and retrospective audits are recommended to ensure all possible diagnoses are captured and the documentation supports the coding. Finally, coupling audits with physician-led peer-to-peer education helps promote rapid behavior change and increase documentation and coding accuracy.

When combined, these actions allow providers “to focus on high-risk patients with early interventions that can lower costs and improve care,” Ramos says. “Our goal is to present meaningful information to the providers that not only address documentation gaps but also improve the patient experience and work toward the quadruple aim.”

— Elizabeth S. Goar is a freelance writer based in Wisconsin.