Costly chronic conditions of ICD-10-CM have been classified by CMS into Hierarchical Conditional Categories (HCCs). Patients with HCC conditions require more resources and disease intervention. The Risk Adjustment process identifies patients who are more costly to care for based on the diagnosis codes billed for the patient in the previous review period. Proper HCC coding and documentation is critical for health care providers participating in risk-adjusted market of Accountable Care Organizations (ACOs), Medicare’s Hospital Value Based Program (HVBP), or Medicare Advantage (MA).

Medicare wants payments to CMS-accepted organizations to be in line with the expected cost of care. To this end, CMS targets health plans with both random and targeted audits to confirm validity of diagnoses submitted. Submitting an inaccurate diagnosis or a diagnosis resulting in a different HCC poses a major compliance risk and will lead to payment recovery to Medicare. Any change in the HCC could mean that the provider is receiving too much or too little revenue. In both cases, the code would be considered invalid or discrepant.

To stay compliant and mitigate risk of audits, healthcare providers must be well aware of the essentials that should be present in the medical record. One of the most critical and basic requirements is proper documentation of the diagnosis to capture the most accurate HCC code. For this, documentation should indicate the diagnoses being monitored, evaluated, assessed/addressed, or treated (M.E.A.T.).

M.E.A.T. stands for: M-monitoring, E-evaluating, A-assessing, and T-treatment. M.E.A.T. is at the heart of HCC coding and clinical documentation and is defined as follows:

  • Monitor-signs, symptoms, disease progression, disease regression
  • Evaluate-test results, medication effectiveness, response to treatment
  • Assess/Address-ordering tests, discussion, review records, counseling
  • Treat-medications, therapies, other modalities

These four factors help providers to establish the presence of a diagnosis during an encounter and ensure proper documentation. For medico-legal purposes, complete documentation provides evidence of a diagnosis, that is, “if it was not documented, it does not exist”.

For success with documentation, clinicians should make sure it adheres to M.E.A.T. guidelines. If M.E.A.T. is not documented to validate the diagnosis, the diagnosis will be rejected by CMS due to the lack of evidence by provider. The following is an example of supported documentation:

Congestive Heart Failure (CHF) – 150.3, symptoms well controlled with Lasix and ACE inhibitor. Will continue current medications”

To indicate HCC diagnosis, providers should:

  • Code all documented conditions that co-exist at the time of the encounter that require patient care, treatment, and management
  • Fully document and accurately code the evaluation and ongoing management of all severe and chronic conditions
  • Document history of heart attack, status codes, etc.
  • Document diagnoses as “history of” or “PMH” only when they no longer exist or are not a current condition
  • Ensure that each note has date, signature and credentials

Medicare focuses on these diagnoses to demonstrate the need for higher reimbursement rates for patients who have more serious conditions or problems to manage. If the ICD-10 code on the claim is not accurate or complete, this would indicate that the provider did much less work (medical decision making, evaluation, and management) than actually performed, leading to lower reimbursement.

Today, the demand for increased specificity under ICD-10 and the growing use of HCCs is driving health care organizations to enhance their clinical documentation improvement (CDI) efforts. While it is up to the physician to accurately, completely, and legibly documenting the services performed, collaborating with a medical coding company with experience in HCC coding would ensure accurate code assignment and proper reporting of diagnoses and procedures. Partnering with the right medical billing and coding company will help providers:

  • Take advantage of Medicare risk adjustment coding opportunities by capturing the most appropriate HCC codes
  • Ensure that all HCC codes reported on the encounter claim are supported by M.E.A.T.
  • Ensure accurate quality measures
  • Boost financial integrity

With their expertise in executing risk adjustment and HCC auditing, a reliable medical coding service provider and can help health care organizations minimize compliance risks, enhance care delivery, and improve data integrity with appropriate diagnostic reporting.