HCC Medical Coding for Risk Adjustment Payment Models
Risk adjustment medical coding is an end-to-end coding system payers use to determine the healthcare costs and utilization associated with treating specific patient populations. This risk adjustment methodology utilizes Hierarchical Condition Categories (HCCs) – representing chronic, and some severe, acute conditions – to group similar diagnoses into one related category (an HCC). HCC medical coding plays a vital role in this process, ensuring that each diagnosis is accurately classified and mapped to the appropriate HCC category for effective risk adjustment and reimbursement.
Under the HCC risk adjustment payment model, documentation specificity, with accurate ICD-10 coding, is key for providing a complete picture of a patient’s health.
Here are some rules to remember:
- Always code to the highest level of specificity to determine the correct HCC medical coding category and reduce denials.
- Medical Coding specificity means reporting all diagnosis codes that identify a patient’s condition, including co-morbidities that impact the current diagnosis and demonstrate the need to deliver the level of care provided.
- Provider documentation is required to support all diagnoses that map to HCC codes. Document and code for any patient condition that is relevant to HCC medical coding:
- Present but stable
- Managed with therapy
- Requires observation
- Requires referral to another provide for management
- Influences the providers decision making in the care of the patient.
- It’s important to document chronic conditions annually, even if they are stable with treatment:
- Clearly note the chronic nature of the condition
- Document its severity, or stage
- Record any associated conditions or complications, and their relationship to the underlying chronic condition
HCC Medical Coding Documentation and Coding Tips
- Arrange meetings with providers and clinical teams to ensure they grasp the significance of accurate ICD-10 diagnosis coding to illustrate risks within their patient population.
- If feasible, leverage your EHR to identify HCC medical coding conditions.
- Establish a protocol to code every chronic condition and diagnosis a patient has at least once annually. Utilize preventive visits to prompt providers to update problem lists and guarantee chronic conditions are coded with the highest level of specificity to capture any complications.
- When selecting ICD-10 codes for each Evaluation and Management (E/M) encounter, document every condition or diagnosis that coexists at the time of treatment, or that influences patient management or treatment. Documentation must support each diagnosis coded during the visit.
- Ensure Assessments & Plans (A/P) clearly identify/diagnose the specific condition and evaluation, and include a clear treatment plan that will support HCC medical coding for the diagnosis.
- Conduct continuous internal audits and monitoring as part of your internal protocol to ensure providers receive feedback and education to address areas that need improvement.
- Maintain accurate, current problem lists so they can be addressed quickly.
- Refrain from coding a condition if it does not pertain to the services rendered during each encounter.
Outsource HCC Medical Coding with CodeEMR
With more payers utilizing HCC risk adjustment payment models, it pays to work with certified professional coders with experience in this specific risk adjustment methodology. Find out how CodeEMR can help keep your HCC medical coding on track for maximum reimbursements and minimal denials.
