Revenue cycle and Coding leadership at any sponsoring Medicare Advantage (MA) organization are responsible for maintaining high accuracy HCC Coding and risk adjustment practices on an annual basis. But as anyone in the business knows, this is easier said than done. With more than 9,700 ICD-10-CM codes mapping to one or more 86 HCC’s1, expertise in risk adjustment coding, which impacts the quality of ongoing patient care delivered, reimbursements recovered, compliance met, and the overall financial health of providers, is critical.
To speak to this, last week ECLAT hosted its first Experience The Brilliance webinar of the year - “A Practical Approach to HCC Coding and Risk Adjustment” centered on this urgent topic of discussion. ECLAT's speakers, Marie Thomas (VP of Revenue Cycle Operations), Evelyn Santos (Coding & Auditing Specialist), and Kara Carlisle (Coding & Auditing Specialist), shared practical examples to shed light on the financial impact HCC reviews for complete documentation can make when looking to achieve optimal Risk Adjustment Factor (RAF) scores.
It's safe to say there is no such thing as being "too ready" for the annual Risk-Adjustment Data Validation (RADV) audits. Ongoing education and training for each calendar year make all the difference. By breaking down the best practices for HCC Coding and the risk adjustment considerations to be incorporated prior to the reporting period, we hope our audience feels more comfortable moving forward in 2021.
If you missed the LIVE discussion, read this recap article as we provide some highlights of the webinar.
What is HCC Coding?
We started the discussion by understanding the basics of HCC Coding or Hierarchical Condition Coding. HCC Coding is not a new concept. The CMS-HCC model was implemented in 2004 as a way for medical groups to estimate a patient's future health care costs in a Value-Based Payment Model.
The Risk-Adjustment classification we discussed during our webinar, was primarily focused on capturing the "financial risk" based on capturing all of the diseases and demographic risks (age, sex, disability, etc.) to yield risk Adjustment Factor (RAF) scores for future Medicare advantage plans. This RAF score is used to determine how sick the patient is every year and whether the care that the patient is provided under the plan year is representative of the patient's risk.
A quick way to remember how to interpret the RAF score methodology is -
"The higher the score, the sicker the patient."
CMS-HCC determines the payments to be made to prospective MA plans according to the documentation coded.
In a value-based payment system, when we look at what is considered in an HCC risk model, there are three sources of data from where the codes are going to be collected for the predictive year.
- Hospital Inpatient
- Hospital Outpatient
- Doctor Visits
CMS-HCC is used by health plans to arrange and/or negotiate payment arrangements for the patient members using risk scores to adjust Medicare's monthly capitation payments to Medicare Advantage (MA) plans.
Addressing the Dilemmas with Value-Based Purchasing/Payment (VBP)
Upon covering the basics of HCC coding, we moved on to addressing some common dilemmas with value-based purchasing:
- It is essential to document, report, and code the entire report of the patient’s chart even when productivity is top of mind
- Use the "M.E.A.T" for Monitored, Evaluated, Assessed, and Treated, criteria to address the specificity in documentation, coding, and reporting
- Make sure that there is an active collaboration among different departments like Admissions, Coding, CDI Services, and Patient Financial Services (PFS) to capture all of the latest and greatest information
- Involve physician practices to collect comprehensive continuum of care
- Managing costs include the ability to predict costs across patient populations
HCC Documentation Considerations
Documentation is essential to capturing all the reportable conditions. Here are some considerations to keep in mind:
- Chronic conditions that meet the necessary criteria to report need to be documented and verified whether they are clinically valid
- Don’t forget any condition that is currently under treatment or management (behavioural health, oncology conditions, etc.)
- Discourage relying heavily on problem lists, this may hinder specificity.
- Condition specificity is important
- Make sure to code to the highest level documented using "with"
- Status conditions are important - any amputations and/or -stomas add risk and will need to be captured every year.
- Query when clarification is needed according to your organization's policy
How are HCCs Calculated?
We also discussed a formula for calculating CMS reimbursement to Medicare Advantage Plans.
Base Rate X RAF = CMS payment to the plan
(PMPM-per member per month-capitation payment)
The Base Rate here is formed based on the HCC codes and the patient’s demographic.
Examples and Case Studies: HCC Coding
The webinar also included HCC coding examples and interactive case studies. We presented two different patient personas with varying health conditions. Participants were then asked to calculate the RAF scores for each persona and determine who is sicker.
Watch the webinar replay and download the handouts to read these case studies.
Getting Ready for CMS RADV Audits
CMS periodically performs Risk Adjustment Data Validation (RADV) audits to match the documentation to the submitted HCC codes. In case of non-compliance and errors, heavy penalties can be levied on providers. In addition, HCCs are re-assigned each year, so providers must continue to document the chronic conditions that require care or impact the patient. Remember, each past and current patient condition must be coded for and documented on an annual basis.
We received a Question during our LIVE Q&A which we are happy to address here:
LIVE AUDIENCE QUESTION
"For a retrospective HCC chart review, what is the time frame for submissions? I was told 365 days from the day of adjudication ... but if I am working on a retrospective project and I want to submit corrections to CMS I am unclear of the time frame."
You have more than 365 days available from the date of claims submission. For e.g., If the claim DOS is 2019 the initial submission will fall in the month of March 2020 and final submission will be in Jan 31st 2021. Even if you miss initial submission timeline, you can still submit before final submission.
Are you Prepared for Deadlines for Submission of Risk Adjustment Data?
Friday, March 5th, 2021, August 2nd, 2021, and September 3rd, 2021 are the upcoming CMS-HCC sample submission deadlines. If you feel like you may be in need of risk adjustment assistance, don't panic. ECLAT Health Solutions has specialized HCC coders ready to help you improve the accuracy of your CMS Audit samples so you can receive optimal reimbursements amid the COVID disturbance.
Explore our HCC Coding Services and how you can partner with us today.