Reporting Chronic Conditions in the Age of Value-based Reimbursement

by | Published on Mar 23, 2018 | Medical Coding

Chronic Conditions
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The shift from fee-for-service to fee-for-value has changed the way physicians provide care, bill for services, and get reimbursed. As three out of four Americans are living with multiple chronic conditions, proper chronic care management is critical to improve quality of care. Reporting chronic conditions correctly is the key to ensuring optimal reimbursement for physicians under the value based care model. As a medical coding outsourcing company, we are well aware that this has put the focus on Hierarchical Condition Category (HCC) coding.

The HCC coding model was introduced by CMS to reimburse Medicare Advantage (MA) plans (Medicare Part C) based on the health of its members. Under the HCC method of risk adjustment, beneficiaries with chronic conditions are assigned a risk score based on their overall health status, relative risk that the condition will get worse, and various demographic characteristics. HCCs reflect members’ diagnoses and are derived from ICD codes via retrospective review of claims data. Payments are based on risk scores derived from the HCCs. Generally, the model assigns higher expenditures for sicker beneficiaries than for healthier ones.

The top 10 HCC chronic condition categories are:

  • Chronic obstructive pulmonary disease
  • Congestive heart failure
  • Vascular disease
  • Cancer
  • Ischemic heart disease
  • Specified heart arrhythmia
  • Diabetes
  • Ischemic or unspecified stroke
  • Angina
  • Rheumatoid arthritis
  • Inflammatory connective tissue disease

Under ICD-10, coding HCCs for these chronic health conditions has become more complex as there are combination codes for conditions, common symptoms, and manifestations. Medical coding service providers need to make physicians aware of the importance of recognizing, documenting, and coding chronic conditions to the highest level of specificity to report each patient’s risk adjustment diagnosis. Reporting this on an annual basis is crucial to ensure quality of care as well as proper funding. Undercoding would lead to underpayment and loss of revenue and overcoding would increase risk of scrutiny and compliance actions. In short, not reporting all conditions properly would negatively impact the provider, payer, and patient.

What are the documentation considerations under the risk adjustment model?

For proper HCC coding, physicians should thoroughly document chronic disease processes and manifestations in the patient’s medical record. The progress note must include the history of present illness, physical exam, and the medical decision-making process. The most important thing is to include M.E.A.T. in risk adjustment documentation, that is, the documentation should contain:

  • M – Monitoring signs, symptoms, disease progression, disease regression
  • E – Evaluating test results, medication effectiveness, response to treatment
  • A – Assessing/Addressing ordered tests, discussion, review records, counseling
  • T – Treating medications, therapies, other modalities

The documentation requirements for well-done M.E.A.T. are as follows:

  • Accurate and thorough documentation of all chronic disease processes and manifestations that are both active and/or have a relevant history
  • Documentation of all conditions evaluated during every face-to-face visit
  • Each progress/subjective, objective, assessment, and plan (SOAP) note must include: history of present illness (HPI), physical exam, and the overall medical decision-making process
  • Every diagnosis reported as an active chronic condition should be documented with an assessment and plan of care

In the value-based reimbursement scenario, physicians can optimize reimbursement and improve quality of care by adhering to Medicare guidelines for reporting chronic conditions:

  • Ensure HCC capture at least once every 12 months
  • Document chronic conditions to the highest level of specificity
  • Report all information from the office visit in the progress notes which affects the plan of care for the chronic condition
  • Document according to the M.E.A.T. principles
  • Document only confirmed diagnoses, not suspected conditions
  • Confirm that the diagnosis codes billed correspond to the documentation
  • In the case of a new patient, discuss and document all chronic conditions at the visit. Do not report the condition again if the condition does not affect the patient’s care 6 months after the initial encounter
  • Ensure the medical record contains the provider’s legible signature

Various federal and state programs, as well as private and commercial insurance plans use risk adjustment payment methodologies. With the increasing number of patients with multiple chronic conditions, ensuring through documentation and accurate HCC coding can be a challenging task for medical practices. Partnering with an experienced medical coding company is a practical option to drive positive outcomes through proper coding of chronic conditions.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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