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Risk Adjustment Hierarchical Condition Coding (HCC Coding). Payment Model Provider Education Guide. What is CMS’s Hierarchical Condition Coding ?. Medicare Risk Adjustment payment model introduced by the Centers for Medicare and Medicaid (CMS) in 2004.

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risk adjustment hierarchical condition coding hcc coding
Risk Adjustment

Hierarchical Condition Coding

(HCC Coding)

Payment Model

Provider Education Guide

what is cms s hierarchical condition coding
What is CMS’s Hierarchical Condition Coding?
  • Medicare Risk Adjustment payment model introduced by the Centers for Medicare and Medicaid (CMS) in 2004.
  • The goal is to pay Medicare Advantage (MA) and Prescription Drug Plans (PDPs) accurately and fairly by adjusting payment for Enrollees based on their demographicsand their health status.
  • This Risk Adjustment payment model measures the disease burden that includes 70 HCC categories, which are correlated to diagnosis codes.
  • Accurate diagnosis code documentation (ICD-9 CM) and reporting now determines reimbursement.
    • 3,600 ICD-9 codes map to 1 of 70 HCCs (mostly chronic but some are acute)
examples of chronic conditions
Examples of Chronic Conditions
  • The following HCCs reflect a few common chronic conditions found in Medicare population, that Medicare Advantage Plans look for to be documented in a patient’s chart:
    • Diabetes without complications – HCC 19
    • Chronic Obstructive Pulmonary Disease – HCC 108
    • Congestive Heart Failure – HCC 80
    • Breast Cancer – HCC 10
    • Ischemic Heart Disease – HCC 92
    • Angina – HCC 83
  • Diagnoses from the previous year are used to establish capitation payments to the MA plan. HCCs must be captured every 12 months for CMS to reimburse. Health Status is re-determined every year
  • If the HCC codes are captured outside the12 months (e.g. 12 months and 4 days), it will generate a 6-month revenue gap for that MA plan.
data collection
Data Collection
  • It all boils down to the data collection process!
  • Physicians who do not exercise good documentation at each patient encounter will receive insufficient funding.
  • Good documentation begins at the time of the patient’s face-to-face encounter with the physician.
  • Document all clinical findings in the medical record (chart), and the medical record is used to support ICD-9-CM and HCC coding.
the process
The Process

Care is Delivered to the Member (face-to-face encounter)

Care and Diagnoses are Documented in the Chart / Progress Notes

ICD-9 CM codes are submitted on Claims based on the face-to-face encounter clinical findings

Plan & Providers can Deliver better care

And reimbursement is received

Claims data diagnosis codes are converted to HCC codes

CMS Calculates MA Risk Adjustment

HCC codes data is submitted to CMS

document document document
Document, Document, Document
  • Is your documentation sufficient to fund the care for your sicker patients?
  • The quality of diagnosis coding and supporting documentation must improve in order to maintain the same reimbursement payments.

It All Begins with You!

Goal = Properly Reflect the Member’s Health Status

  • Fully assess ALL Chronic Conditions ….…at least annually
  • Thoroughly Document in the Chart (Progress Notes) ALL conditions evaluated for each visit
  • Code to the Highest Level of Specificity (fully utilize the ICD-9 Diagnosis Coding System)
choosing diagnosis codes
Choosing Diagnosis Codes
  • A joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
  • Annual code changes are implemented by the government and are effective Oct 1 of every year and valid through Sept 30 of the following year.
diabetes mellitus
Diabetes Mellitus
  • All important 4th digit
    • 250.00 no complication
    • 250.10ketoacidosis
    • 250.20hyperosmolarity
    • 250.30 coma
    • 250.40 renal manifestations
    • 250.50opthalmological manifestation
    • 250.60 neurological circulatory disorders
    • 250.70 peripheral circulatory disorders
    • 250.80 other specified manifestations
diabetes manisfestations
Diabetes Manisfestations
  • Use multiple coding techniques for compound diagnoses
  • DM with a manifestation (complication) requires that you document and code the manifestation as well.
  • Peripheral Neuropathy due to DM
    • 250.60 DM with Neurological manifestations
    • 357.2 Peripheral Neuropathy in DM
  • PVD due to DM
    • 250.70 DM with peripheral circulatory disorders
    • 443.81 PVD in diseases classified elsewhere
esrd coding
ESRD - Coding
  • When a patient is on dialysis it requires two codes
    • 585.6 ESRD $2870
    • V45.11 Renal Dialysis Status $10,522
  • ESRD on hemodialysis due to Diabetes
    • 250.40 Diabetes w/renal manifestations $3962
    • 585.6 CKD stage VI (ESRD)
    • V45.11 Renal dialysis status $10,522
    • ** CKD hierarchs Nephropathy
documenting the diabetic connection
Documenting the diabetic connection
  • Unclear whether “with” will be acceptable with CMS so preferable way to make connection
    • “Due to”
    • “Secondary”
    • “Diabetic”
  • Examples:
    • Peripheral Neuropathy due to DM
    • CKD Stage III secondary to DM
    • Diabetic Ulcer
    • Diabetic Retinopathy
documenting the diabetic connection1
Documenting the diabetic connection
  • Coders are not allowed to assume a cause-and-effect relationship
  • If you document like this:
    • Assessment
      • 1. Diabetes Type II 250.00$1263
      • 2. Peripheral Neuropathy 356.9$2550
      • 3. CKD Stage III 585.3 $2870
  • These will be coded separately and the highest Diabetes HCC code will be missed
  • If you document like this, then the highest HCC in the diabetes will be captured:
    • Assessment
      • 1. Diabetic peripheral neuropathy 250.60 & 357.2 $2550
      • 2. CKD III due to Diabetes 250.40 $3962 & 585.3 $2870
ulcers non pressure vs pressure
Ulcers-Non Pressure Vs. Pressure
  • Two types of ulcers
    • Non-pressure of chronic $3502
    • Pressure or Decubitus $8993
  • Pressure ulcer is a higher HCC than a non-pressure so it’s important to code it correctly
    • Stage I pressure ulcer of sacrum
      • 707.03
      • 707.21
    • Diabetic ulcer on the calf
      • 250.80 DM with other specified manisfestations
      • 707.12 Ulcer of the calf
  • **Wounds are not HCC’s
metastatic cancer
Metastatic Cancer
  • Mets is the highest HCC $17,753– only if the site it has metastasized to is documented
    • H/O Breast Ca with Mets to lung V10.3 & 197.0
    • Prostate Ca on Lupron with bone Mets 185 & 198.82
    • H/O Colon Ca with Mets to the liver V10.05 & 197.7
  • If you document like this the highest HCC opportunity will be missed
    • Metastatic Breast Ca $1622 (if Breast ca is under treatment) 174.9 & 199.1
    • Metastatic Colon Ca $1622 (if Colon ca is under treatment) 154.0 & 199.1
    • Lung Ca with Mets $8213 (if Lung ca is under treatment) 162.9 & 199.1
    • H/O Lung Ca with Mets $1622 V10.11 & 199.1
alcohol and drug dependence
Alcohol and Drug Dependence
  • Alcohol dependence, Chronic alcoholism or Alcoholism in remission 303.90 & 303.93
  • Drug dependence or Drug dependence in remission
  • (opiate, anxiolytic, sedative, hypnotic, hallucinogen, or amphetamine) 304.90 & 304.93
  • Patient has arrived at a stage of physical dependency and would experience physical signs of withdrawal with sudden cessation
  • **Alcohol abuse and drug abuse are not HCCs! 305.xx
major depression malnutrition
Major Depression/Malnutrition
  • Major depression 296.xx
    • PHQ9 score > 10
    • 5 of 9 DSMIV criteria
    • Medication
    • Following with a mental health provider
    • **if only “Depression” 311 is documented…it is not an HCC code!
  • Protein Calorie Malnutrition 263.x
    • Commonly used indicators
      • Albumin <3.4
      • 10% unintentional weight loss in 3-6 mos
      • 5% unintentional weight loss in 3-6 mos
      • BMI <18.5, especially with a co-morbidity
      • Poor nutrition or loss of appetite
      • Wasting appearance or muscle wasting
common omissions year over year
Common Omissions Year over Year
  • Artificial openings
    • GastrostomyV44.1
    • Colostomy V44.3
    • TracheostomyV44.0
    • IleostomyV44.2
  • Amputations
    • BKA V49.75
    • AKA V49.76
    • Foot V49.73
    • Toe V49.71 or V49.72
  • AAA – Abdominal aortic aneurysm 441.4 (w/o repair)
  • Aortic Atherosclerosis 440.0
malfunctions complications
Malfunctions / Complications
  • Mechanical complication of device, implant or graft 996.xx
    • Vascular, Nervous, Genitourinary, Internal orthopedic
  • Infection/Inflammatory reaction due to internal device, implant or graft 996.xx
    • Cardiac
    • Vascular
    • Nervous System
    • Indwelling catheter
    • Internal joint prosthesis, ortho or prosthetic device
  • Other complications of device, implant or graft – occlusion, embolism, fibrosis, hemorrhage, pain, stenosis, thrombus 996.xx
    • Vascular device, implant or graft
    • Nervous system device, implant or graft
    • Genitourinary device, implant or graft
    • Internal joint prosthesis
examples of how much it matters
Examples of how much it matters?

HCC CodeAnnual Reimbursement

  • HCC19 250.00 Diabetes with no complications $ 485
  • HCC18 250.5x D. w/ ophthalmic manifestations $ 831
  • HCC17 250.1X –3X D. w/ acute complications $ 948
  • HCC16 250.6x D. w neurologic manifestations $1,338
  • HCC15 250.4x D. w/ renal or peripheral circulatory manifestations $1,852

Note: Some categories have a hierarchy, such as Diabetes, in such categories, only the highest HCC would “count”

  • Don’t report this If the pt really has

(Does not risk adjust) (Does risk adjust)

311 Depression 296.xx Major Depression

493.90 Asthma 493.20 Chronic Obst Asthma

496 COPD/492.8 Emphysema

490 Bronchitis 491.9 Chronic Bronchitis

414.01 CAD 413.9 Angina 411.1Unst Angina

427.89 Cardiac Dysth427.31Atrial Fib

577.0 Pancreatitis C 070.54 Chronic Pancreatitis

070.70 Hepatitis C 070.54 Chronic Hepatitis C

805.8Fx of Vertebrae 733.13 Path FX of Vertebrae

436 CVA 437.20 Lt Eff CVA Hemiplegia

additional coding examples
“Additional Coding Examples”

Does Risk Adjust:

~ 402.00 Hypertensive Heart

DX-Malignant w/o heart failure

~ 413.9 Angina pectoris unspecified

~ 430.3 Atherosclerosis of by-pass graft of extremities

~ 427.3 Atrial fibrillation

Does NOT Risk Adjust:

~401.0 Hypertension benign

~ 414.00 Coronary athersclerosis

~ 449.9 Atherosclerosis unspecified

~ 427.89 Other specified cardiac


documentation tips
Documentation Tips
  • Don’t document “H/O” of any disease that currently exists.
    • The statement “history of” in ICD-9 terms means that the patient no longer has this condition. However, “H/O” is ok when documenting some status conditions such as Amputation, Old MI or Cancer.
  • Rule of thumb in coding is
    • If a patient is on a medication for a condition and if the medication were to be stopped, would the condition resume, and the answer is mostly likely or yes, then you still code the condition.
      • Examples
        • H/O CHF – pt is on lasix428.0
        • H/O Angina – pt has nitroquick413.9
        • H/O COPD – pt is on Advair496
    • This also applies to a pacemaker for SSS or Complete or 3rd degree heart attack..if the SSS or Heart Block is documented you can still code it 427.81 or 426.0
treating managing or assessing the chronic conditions
Treating, Managing or Assessing the Chronic Conditions
  • In order for CMS to make the payment to the health plan the diagnoses submitted must be from a face-to-face visit and the visit must indicate how the chronic conditions are being treated, managed or assessed
    • Sample language
      • AssessmentPlan
      • Stable Monitor
      • Improved D/C meds
      • Tolerating meds Continue meds
      • Deteriorating Refer
    • Example: Hypertensive CKD III, stable well controlled, continue meds
    • Example: COPD, stable on Advair
critical success factors coding guidelines
Critical Success Factors – Coding Guidelines
  • “Probable”, “suspected”, “questionable”, “R/O”, “versus”, “working diagnosis”, “?”, “likely”, etc. CANNOT be coded!
  • Code the condition to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
  • A medical record entry must
    • Be legible
    • Support all diagnoses coded
    • Be complete and accurate
    • Have a provider signature and credentials
    • Identify the patient and date of service
    • Document the patient’s progress and results of treatment
    • Justify the treatment and level of care
    • Use only standard abbreviations and keep them to a minimum
    • Promote continuity of care among the healthcare providers
coding guidelines
Coding Guidelines
  • Coded according to the ICD-9-CM Guidelines for Coding and Reporting; assigned based on dates of service within the data collection period,
  • Submitted to the MA organization from an appropriate risk adjustment provider type and an appropriate risk adjustment physician data source.
  • The medical record documentation must support an assigned HCC.
  • All chronic conditions must be assessed and reported no less than once a year… “If a patient is Diabetic, it must be in the chart every year”!
  • All conditions must be documented in the medical record.
  • Medical record must support codes reported on the claim or encounter form.
  • Provider should document and code to the highest level of specificity.
  • Each diagnosis must have an assessment and a plan.
coding guidelines1
Coding Guidelines

Which Medical Record(s) can be submitted for validation?

  • Hospital Inpatient
  • Hospital Outpatient
  • Or Physician medical record when more than one option is available.

What must Providers report?

  • All diagnoses (not just primary diagnosis) that impact the patient’s evaluation, care, and treatment including:
    • Main reason for visit,
    • Co-existing acute conditions,
    • Chronic conditions (such as A Fib, CHF, CKD, RA, DM, COPD/Asthma, Cardiomyopathy),
    • Care rendered,
    • Conclusion and diagnosis,
additional coding guidelines
Additional Coding Guidelines
  • Incomplete Inpatient Records
    • Discharge summary
      • Valid IP record for coding if it has both the admit and discharge dates
      • Use Inpatient Coding guidelines to code
    • Admission history and physical not valid for IP record coding
    • Consults during the inpatient stay may be coded as physician records
      • Use Inpatient Coding guidelines to code
    • ER visit on the same date as admission date can be coded as an outpatient visit
      • Use Inpatient Coding Guidelines to code
example of good documentation
Example of Good Documentation

Chief Complaint

  • S: Voices no complaint except that she wishes she could visit her sister, who is hospitalized. States she is able to get around, including bathroom and cafeteria, without difficulty. Denies any pain or shortness of breath. No change in bowel or bladder habits.
  • O: Patient alert, oriented to person, disoriented to place and time. No acute distress.
  • Cardiac: RRR no rubs, gallops or murmurs noted
  • Lungs CTA bilat. No cough or wheezing noted.
  • Abd soft non tender to palpitation with Colostomy intact, skin dry and intact surrounding pink-red stoma, liquid brown feces.
  • Diminished sensation LE bilaterally, skin cool with rubor.
  • Old incision for L great toe amputation dry and intact. Able to ambulate to toilet and cafeteria with walker.
  • A: 250.70 Diabetes with peripheral circulatory disorders, currently controlled; with 443.81 peripheral vascular disease due to diabetes; and 250.60 diabetes with neurologic manifestations of 357.2 diabetic polyneuropathy.
  • Finger stick blood sugar ranges 125-175 in past 2 weeks. Diabetes controlled on current regimen a.c. & h.s. insulin; sliding scale insulin if needed. V55.3 Functioning colostomy, no change in plan of care.
  • V49.71 Old amputated L great toe - stable.
  • 290.40 Mild senile dementia (see notes October 10, 2006)
  • 733.13 Osteoporosis with vertebral fractures (see notes September 13, 2006).
  • P: Continue current diet & insulin regimen. Retain sliding scale order for prn with notification parameters. Continue current activity level.
  • Authenticated by: Physician, MD
  • Clear, Concise, Consistent, Complete, and Legible
  • SOAP Approach: Subjective, Objective, Assessment, Plan
  • Problem List Approach: a numbered and dated index of patient’s problems kept in front of medical record, from identification through resolution
  • Reason for Visit: This is the chief complaint of the patient:
    • “weakness, headache, and liver cancer”
  • Care Rendered: This is what was done to address the chief complaint.
    • “examination and blood work”
  • Conclusion and Diagnosis: This is the outcome of the findings based on the care rendered.
    • “Anemia with coexisting conditions of Adult onset diabetes, neuropathy, COPD, and Asthma”
top ten hcc groups
Top Ten HCC Groups
  • COPD $3112

496 COPD

493.20 Asthma w/ chronic COPD (Chronic Obstructive Asthma)

491.9 Chronic Bronchitis

492.8 Emphysema

  • CHF $3198

428.0 CHF

425.4 Primary Cardiomyopathy (Ischemic is not an HCC)

402.91 Hypertensive Heart Disease w/ heart failure

  • Vascular Disease $2465

443.9 Peripheral Vascular Disease

443.81 PVD in other diseases (diabetes)

453.40 Acute DVT

440.0 Atherosclerosis of Aorta

441.4 Abdominal Aortic Aneurysm

  • Cancer $1622-$8213

All malignant neoplasm’s including Melanoma but not skin cancer

All secondary malignant neoplasm’s – Highest HCC if site is documented $17,753

top ten hcc groups1
Top Ten HCC Groups
  • Ischemic Heart Disease $2215

411.1 Unstable Angina

  • Specified Heart Arrhythmia $2285

426.0 Complete AV block

427.31Atrial Fibrillation

427.81 Sick Sinus Syndrome

  • Diabetes $1264-$3962

All diabetes (250.xx) and most of the manifestations

  • Ischemic or Unspecified Stroke $2067

436 CVA

434.91 Unspecified cerebral artery occlusion, w/ infarction

  • Angina/Old MI $1903

413.9 Angina

412 Old MI

  • Rheumatoid Arthritis & Inflammatory Connective Tissue Disease $2699

714.0 Rheumatoid Arthritis

710.0 SLE



other common hcc codes
Other Common HCC Codes
  • 340 Multiple Sclerosis
  • 332.0 Parkinson's
  • 345.90 Seizure Disorder
  • 362.02 Proliferative Diabetic Retinopathy
  • 042 HIV
  • 571.5 Liver Cirrhosis
  • 556.9 Ulcerative Colitis
  • 344.1 Paraplegia
  • 344.00 Quadriplegia
  • CMS audits medical records to validate documentation.
  • Validation Audits
    • Superbills are not considered sufficient documentation … they are a reporting format only.
    • Documentation must show the diagnosis was assigned within the data collection period.
    • Data discrepancies that are found as a result of audit may cause a risk adjusted payment to be changed.
contact information
Contact Information
  • Please remember, “If it’s not documented, then…. It didn’t happen”
  • Use proper ICD-9 CM coding and specificity

Please call or email us at anytime for questions or for assistance

We welcome your feedback and appreciate your cooperation.