Accurate capture of patient risk is crucial for successful performance in value-based care arrangements, which are aimed at promoting better care and health for individuals at a lower cost. Accurate coding and documentation of chronic and complex diagnoses each calendar year is essential to generate patient risk scores to reflect the relative health or sickness of patient. Outsourcing medical billing and coding can help practices with risk capture, provide the right care at the right time, and maximize reimbursement.
The general goal of value-based payment is to reward physicians who provide high-quality care. However, health risks vary among patients. Complex or serious medical problems require specialized care and are time consuming and costly to treat. These illnesses include diagnosed cardiovascular disease (CVD), Type 2 diabetes, or type 1 diabetes with or without cardiovascular risk factors and/or target organ damage, chronic kidney disease, severe hypertension, abdominal obesity, and low physical activity levels, and dementia.
CMS’s Hierarchical Condition Categories (HCC) risk-adjustment model is designed to estimate future health care costs for patients. The diagnostic categories cover high-cost chronic diseases and some acute conditions. There are 19 different HCC categories with 86 total HCC codes.
Accurate HCC coding is critical to ensure appropriate compensation based on the health severity of their patient population. Risk adjustment coding involves utilizing the entire health record for ICD-10-CM coding. The question is how can you accurately report patient risk for value-based payment. Here are 10 tips to do so, including recommendations from the American Academy of Family Physicians (AAFP):
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- Focus on documenting diagnoses correctly: As patient risk scores determine payment in the value-based approach, diagnostic specificity has become crucial. The focus must be on using the correct ICD-10 codes (which map to HCC codes) to accurately document diseases and comorbidities.
- Ensure specificity in clinical documentation: High-quality documentation is required to support HCC reporting. The EHR problem list comprises current and active diagnoses as well as past diagnoses relevant to the current care of the patient. Specificity in clinical documentation is essential for the coding professionals to determine if a condition is current and active.
- Code and report current and active diagnoses each year: As HCC codes are reset each year, every patient’s active diagnoses must be reported every year for accurate calculation of the patient’s overall risk. The AHIMA recommends the following documentation best practices:
- Documenting all cause-and-effect relationships.
- Correctly linking complications or manifestations of a disease process.
- Including all current diagnoses as part of the current medical decision-making process and document them in the note for every visit.
- Diagnoses should be documented as “history of ” or ” past medical history (PMH)” when they no longer exist and are resolved.
Annual wellness visits are the best time to complete HCC documentation. An HCC code can be used for a condition that is addressed during a Medicare wellness visit but is not the primary diagnosis for the visit.
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- Report chronic conditions annually: Starting in 2016, chronic conditions identified are based upon ICD-10 codes for the full year. As many chronic conditions are HCCs, physicians should focus on addressing each chronic condition at least once annually and report the appropriate diagnosis codes.
- Focus on accuracy: Accurate and specific documentation of the patient’s conditions can help improve care quality for patients with chronic conditions. For example, accurate diagnostic data can help identify patients for depression screening and fall risk services. Appropriate interventions can reduce overall healthcare spending for high-risk patients.
- Try to avoid unspecified and symptom codes: Symptom codes (ICD-10 Code range R50-R69, General symptoms and signs) do count for risk adjustment. As far as possible, use the applicable diagnosis codes.
- Report secondary diagnoses addressed during the visit: The CMS Official Guidelines for Coding and Reporting (OCG) state: “Other diagnoses” are interpreted as additional conditions that affect patient care in terms of requiring 1 or more of the following:
- Evaluation
- Treatment
- Diagnostic procedure
- Increased nursing care or monitoring
- Extended length of stay
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There are certain secondary conditions that risk adjust and which physicians address though they are not the primary reason for the visit. Such risk-adjusted secondary diagnoses should be reported if they helped manage the primary reason for the visit.
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- Code disease complications: Many conditions that risk adjust come with complications. For instance, the complications of diabetes mellitus arec cardiovascular disease, neuropathy, nephropathy, retinopathy, foot damage, skin conditions, hearing impairment, and Alzheimer’s disease. Coding for the complications as well as the underlying condition will increase patient risk adjustment.
- Avoid undocumented codes: Assessing large volumes of medical records to assess claims for possible undocumented/incorrect codes to determine more accurate risk scores is a time-consuming and challenging task for coders. Not documenting all conditions clearly can leave money on the table. Accurately document all clinical conditions and comorbidities to ensure accurate ICD-10 coding, quality care, and optimal reimbursement.
- Know the difference between History and Active Condition codes: Understanding the ICD-10 guidelines for coding between history of OR active conditions is crucial to proper risk-adjustment coding. The diagnosis codes for current or active conditions have HCC weighted scores, but the past history of such conditions do not. Coders need to interpret the provider’s documentation when it comes to a patient’s history vs their current active condition and will query the physician to ensure HCC coding accuracy.
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Specificity in documentation and coding is key to providing a complete picture of patient health in the HCC risk adjustment approach. Established medical billing companies have certified medical coders who stay updated on coding changes and can accurately report diagnoses to help practices improve their performance under risk-based payment.
Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.