HCC Coding

HCCs are increasingly used as a way to risk-adjust patients in multiple VBR programs. For example, CMS HCCs are used as a factor in calculating the total performance score (TPS) under the Hospital Value-Based Purchasing (VBP) Program, and they are often used in shared risk and shared savings program metrics.

HCC & Risk Adjustment Factor

• HCC (Hierarchical Condition Categories) is a model implemented to adjust capitation payments to private healthcare plans for the health expenditure risk of their enrollees
• The CMS risk adjustment model measures the disease burden that includes 79 HCC categories, which are correlated to diagnosis codes
• The HCC model is made up of 10,000+ ICD-10 codes that typically represent costly, chronic diseases such as:
  • Diabetes
  • Chronic kidney disease
  • Congestive heart failure
  • Chronic obstructive pulmonary disease
  • Malignant neoplasms
  • Some acute conditions (MI, CVA, hip fx)

Risk Score Development

The Risk Adjustment Factor (RAF score) is set for each patient and includes:

• Baseline demographic elements (age/sex, dual eligibility status).
• Incremental increases based on HCC diagnoses submitted on claims from face to face encounters with qualified practitioners during the calendar year.
• HCC coding is prospective in nature - the work you do in this year sets the RAF and subsequent funding for next year.
• All models include chronic conditions that do not change from year to year, i.e., diabetes, COPD, CHF, Atrial-Fib, MS, Parkinson’s, Chronic Hepatitis.

Coding Team Midas IT Services

• Our fully-employed team of certified coders can scale quickly and complete projects of any size with the maximum level of accuracy, and following a rigorous quality assurance process.
• CPC/CRC Certified coders to perform chart review to identify all HCC conditions.
• Coders are well versed with CMM HCC specifications and ICD-10 CM coding guidelines .
• Certified physician auditors to ensure 98% accuracy.
• AHIMA approved ICD-10 coding trainers.

Chart Review

• Capturing of all HCC codes with assigned HCC condition category, Documentation must show that condition was monitored, evaluated, assessed, or treated (MEAT).
• Follow ICD-10 Official Guidelines for Coding and Reporting. Adherence to these guidelines is required under HIPAA.
• Coding of all ICD-10 CM codes mapped to 79 HCC categories.
• Review of complete medical record, not only from problem list or PMH.
• Identification of conditions which are not documented but billed.

MEAT for HCC conditions

Risk Adjustment Calculation

• Individual risk scores are calculated by adding the coefficients associated with each members demographic and disease factors.
• RAF calculation at the member and practice/plan level.
• RAF improvement for each member (Last year base RAF score to be shared by client).

HCC Reporting

• Average HCC per member within reviewed population.
• Top 10 HCC conditions, raw data also can be shared based on client requirements.
• Top 10 HCC conditions with higher RAF value.
• Identification of Undocumented HCC conditions to eliminate coding compliance risks.
• Weekly/monthly project review to share progress.
• Project end summary with complete output details.

Output Files Submission

• HCC output files submission in standard file format or client preferred format if any.
• 100% quality audit on output files to reduce any data discrepancy.
• Secure data files sharing via SFTP or encrypted files.