Some Transplant Status HCC Codes Medical Coding Companies Must Know

Some Transplant Status HCC Codes Medical Coding Companies Must Know

Accurate HCC coding is essential for anticipating future healthcare financial resources, so that physicians can claim appropriate reimbursement. The HCC model is a value-based payment model implemented in 2004 to assign Risk Adjustment Factor (RAF) to each Medicare patient to estimate the probable costs that the patient may incur during his/her lifetime. It helps the health practitioners to effectively communicate with the patient, the complexity of his or her health status. HCC codes are directly tied to ICD-10 codes and HCC coefficients depend upon the patient category.

The risk scores are assigned based on demographic factors such as age, gender and ethnicity.

Why transplant status HCC coding is important

  • Chronic conditions of the patient like heart disorder, diabetes and cancer need to be actively treated as it may seriously affect the patient’s health. Status codes are necessary to help the physicians identify the significant medical events that the patient experienced in the past.
  • Enables confirmed diagnosis which is important to treat a patient on a long-term basis and anticipate the required patient care in the future.
  • Chronic conditions are part of the patient history and there are chances that it may not necessarily treated at every encounter. This increases the chances of missing out on reporting the appropriate codes.
  • Erroneous documentation of complex diagnosis can lead to under reporting during claim submission for reimbursement.

The figure below shows the cost analysis when transplant status is correctly coded:

hcc coding example

Important transplant status codes

Identifying whether the patient has a history of organ or tissue transplant is the pre-requisite to capture transplant status codes. Transplant patients need close monitoring and superior care as they require long-term medication. Physician coding companies can assist with error-free documentation of transplant status HCC codes as these codes are determinant of the cost-metrics. Failing to appropriately report transplant status codes could lead to substantial loss of revenue opportunities.

  • Z94 Organ transplant status

    Category Z94 codes identify post-transplant status when there are no complications of the transplanted organ. A code from this category is appropriate as an additional code when a post-organ transplant patient presents for treatment of a condition that does affect the function of the transplanted organ.

    • Z94.0 Kidney transplant status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant

    Excludes 1: Complications of transplanted organ or tissue.
    Excludes 2: Presence of vascular grafts.

    • Z94.1 Heart transplant status

    Excludes1: artificial heart status (Z95.812) Heart-valve replacement status (Z95.2-Z95.4)

    • Z94.2 Lung transplant status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant.

    Excludes1: Complications of transplanted organ or tissue.
    Excludes2: Presence of vascular grafts.

    • Z94.3 Heart and Lungs Transplant Status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant.

    Excludes1: Complications of transplanted organ or tissue.
    Excludes2: Presence of vascular grafts.

    • Z94.4 Liver transplant status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant.

    Excludes1: Complications of transplanted organ or tissue.
    Excludes2: Presence of vascular grafts.

    • Z94.5 Skin transplant status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant.

    Excludes1: Complications of transplanted organ or tissue.
    Excludes2: Presence of vascular grafts.

    • Z94.6 Bone transplant status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant.

    Excludes1: Complications of transplanted organ or tissue.
    Excludes2: Presence of vascular grafts.

    • Z94.7 Corneal transplant status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant.

    Excludes1: Complications of transplanted organ or tissue.
    Excludes2: Presence of vascular grafts.

    • Z94.8 Other transplanted organ and tissue status

    Includes: organ or tissue replaced by heterogenous or homogenous transplant.

    Excludes1: Complications of transplanted organ or tissue.
    Excludes2: Presence of vascular grafts.

    • Z94.81 Bone marrow transplant status
    • Z94.82 Intestine transplant status
    • Z94.83 Pancreas transplant status
    • Z94.84 Stem cells transplant status
  • Z94.9 Transplanted organ and tissue status, unspecified.

Includes: organ or tissue replaced by heterogenous or homogenous transplant.
Excludes1: Complications of transplanted organ or tissue.
Excludes2: Presence of vascular grafts.

Unlike other code sets, HCC coding requires additional precision. Medical billing and coding companies assist health practitioners to efficiently manage their revenue cycle. Clinical documentation is enhanced by adhering to reimbursement schedules and compliances.

Risk Adjustment And HCC Coding Best Practices [Infographic]

Risk Adjustment And HCC Coding Best Practices [Infographic]

Hierarchical Condition Category or HCC coding helps paint a picture of the whole patient and communicate patient complexity. Correct HCC coding enables better health management and helps proper assessment of quality and cost performance for accurate reimbursements from Medicare Advantage plans. Not adhering to risk adjustment and HCC coding requirements can adversely impact practice/hospital revenue. Risk adjustment is a method to offset the cost of providing health insurance for individuals with chronic health conditions. In a risk adjustment model, the payment rate for each patient depends on a variety of factors that determine the amount of risk/work involved to provide care for the patient. There are various risk adjustment models. HCC relies on ICD-10 coding to identify a patient’s health conditions and assign a risk score. The CMS uses HCC method to calculate risk scores. Partnering with an expert medical coding service provider can ensure appropriate reimbursement and reduce risk of denials and audits.

Check out the infographic below

Risk Adjustment and HCC Coding

BC Advantage Magazine’s February Edition Features Two Articles by OSI

BC Advantage Magazine’s February Edition Features Two Articles by OSI

The highly acclaimed CEU-approved national online healthcare publication, BC Advantage Magazine, featured two articles “Two Common Knee Ligament Injuries and Their ICD-10 Codes” and “Risk Adjustment and HCC Coding – A Look at Best Practices ” by Outsource Strategies International (OSI) – a Managed Outsource Solutions service – in February 2021. The article was published in the Coding Category.

The article titled, “Two Common Knee Ligament Injuries and Their ICD-10 Codes” looks at two common types of knee ligament injuries and their related ICD-10 codes.

BC Advantage Magazine’s

The two knee ligament injuries are those occurring to the Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL). The former refers to a tear or sprain of the anterior cruciate ligament (ACL), one of the key ligaments in the knee joint. This ligament that connects the bottom of the thighbone (femur) to the top of the shinbone (tibia) helps stabilize your knee joint. ACL injury most commonly occurs during sports activities such as soccer, basketball, football and downhill skiing that involve sudden stops or changes in direction, jumping and landing, which can put additional stress on the knee. The PCL, which is located at the back of the knee, connects the femur (thighbone) to the tibia (shinbone) and keeps the tibia from moving backwards too far. PCL injury happens mostly during motor vehicle incidents and during involvement in contact sports such as football and soccer.

Other topics discussed in this comprehensive article include: symptoms and diagnosis of ACL and PCL. It also discusses how to document the condition and the ICD-10 codes to report these injuries under different circumstances.

“Risk Adjustment and HCC Coding – A Look at Best Practices” discusses risk adjustment – a method used to offset the cost of providing health insurance for people with chronic health conditions who represent a relatively high risk to insurance companies – and the Hierarchical Condition Category (HCC) method to calculate those risk scores.

BC Advantage Magazine’s

HCC coding helps “communicate patient complexity and paint a picture of the whole patient”, according to the American Academy of Family Physicians. Accurate HCC coding enables better health management and helps proper assessment of quality and cost performance for accurate reimbursements from Medicare Advantage plans. Non-adherence to the risk adjustment and coding requirements for Medicare Advantage can adversely impact medical practice/hospital revenue.

The article provides a comprehensive view of HCC coding – the common HCC codes, key considerations for accurate HCC coding, and best practices for HCC coding.

Established in 2002, OSI is a healthcare business process outsourcing company based in the U.S. The company provides end-to-end medical billing and coding services and practice management solutions for all medical specialties, from front office administrative management to back office coding, billing and collections. They serve medical practices, physicians, dental practices, and dentists. OSI’s medical billing team is also specialized in insurance eligibility verification and authorization.

OSI’s team of skilled AAPC-certified coders have a strong understanding of HCC coding, ICD-10-CM and CPT requirements and procedures, and stays up-to-date with coding changes, payer-specific documentation requirements, and state and federal regulations.

This medical billing company strives to leverage their medical billing and coding expertise to provide customized solutions for all medical specialties. The company’s experience and expertise have been recognized by BC Advantage Magazine, the largest independent resource provider in the industry for medical coders and billers, healthcare auditors, practice managers, compliance officers, and clinical documentation experts.

The magazine’s online medical coding article section had earlier featured two other articles from OSI: “ICD-10 Codes for Some of the Worst Epidemics in the U.S.” on February 19, 2020 and “Thanksgiving-Specific Foodborne Illnesses – Types, Symptoms, and ICD-10 Codes” on November 26, 2019.

Risk Adjustment and HCC Coding – A Look at Best Practices

Risk Adjustment and HCC Coding – A Look at Best Practices

The main aim of Hierarchical Condition Category (HCC) coding is to help “communicate patient complexity and paint a picture of the whole patient”, according to the American Academy of Family Physicians. Correct HCC coding enables better health management and helps proper assessment of quality and cost performance for accurate reimbursements from Medicare Advantage plans. Non-adherence to the risk adjustment and coding requirements for Medicare Advantage can adversely impact practice/hospital revenue.

Risk Adjustment and HCC Coding

People with chronic health conditions represent a relatively high risk to insurance companies. Risk adjustment is a method to offset the cost of providing health insurance for such individuals. Risk adjustment models use a person’s demographic data and diagnoses to determine a risk score, which is a relative measure of the costs to insure that person. In a risk adjustment model, the payment rate for each patient depends on a variety of factors that determine the amount of risk/work involved to provide care for the patient. For instance, a patient with less serious health conditions could be expected to have average medical costs for a given time, while a patient with multiple chronic conditions would have higher than average health maintenance costs.

There are various risk adjustment models. The Centers for Medicare & Medicaid Service (CMS) uses the Hierarchical Condition Category (HCC) method to calculate risk scores. HCC relies on ICD-10 coding to identify a patient’s health conditions and assign a risk score. Each HCC is mapped to an ICD-10 code. There are more than 70,000 ICD-10 codes. CMS has released the initial ICD-10 Mappings and Software for 2021 and the HCC model includes 9,757 ICD-10 codes with 86 HCC categories.

Common HCC Codes

HCC 9 Lung and other Severe Cancers
HCC 11 Colorectal, Bladder and other cancers
HCC 12 Breast, Prostate, and Other Cancers and Tumors
HCC18 Diabetes with chronic complications
HCC 19 Diabetes without complications
HCC 22 Morbid obesity
HCC 23 Other Significant Endocrine and Metabolic Disorders
HCC 27 End stage liver disease
HCC 40 Rheumatoid arthritis
HCC 59 Major Depressive, Bipolar, and Paranoid Disorders
HCC 77 Multiple Sclerosis
HCC 79 Seizure Disorders and Convulsions
HCC 85 Congestive Heart Failure
HCC 96 Specified heart arrhythmias
HCC 111 Chronic Obstructive Pulmonary Disease

Key Considerations for Accurate HCC Coding

  • Appropriate capture and documentation of HCC codes for patients is essential for determining accurate risk adjustment scores.
  • All chronic conditions should be monitored. CMS requires that all qualifying conditions be documented at least once a year.
  • Physicians must thoroughly report a patient’s risk adjustment diagnosis based on clinical medical record documentation from a face-to-face encounter.
  • The patient medical record should be coded accurately and accompanied by supporting documentation about the status of each condition.
  • To capture the most accurate HCC code, physicians must document all active chronic conditions including conditions that are relevant to the patient’s current care, i.e., the diagnoses being monitored, evaluated, assessed/addressed, or treated – M.E.A.T.
  • Each diagnosis should have an assessment and plan, and treatment and level of care must be acceptable.
  • Documentation linked to a non-specific diagnosis, as well as incomplete documentation, can negatively impact patient care and also reimbursement for the services rendered.

Best Practices for HCC Coding

  • Educate Providers: Physicians should be educated on how risk-based contracts work and the importance of HCC coding and the need for proper documentation for patients with chronic conditions. Clinic staff should also be educated about the tools and workflows for patient management and reporting.
  • Identify most Frequently Encountered Patient Conditions: Practices should be familiar with the most prevalent HCCs, identify the codes most relevant to them, and ask physicians to focus on these conditions (www.healthcatalyst.com).
  • Prepare for each Patient Visit: When seeing complex HCC patients, physicians should prepare in advance of the appointment. This will help them document and address chronic conditions more accurately and document their findings in the medical record.
  • Prepare an Accurate Problem List: Healthcare organizations need to optimize their EMR and ensure an accurate problem list by removing duplicative and inactive diagnoses, and using a diagnosis preference list to include HCC suffix codes and RAF values.
  • Document Chronic Conditions even if not Treating them: Even if the physician is not seeing a patient for a chronic condition, it should be documented. For instance, if an orthopedist is treating a patient for a knee condition and the patient has diabetes, the physician should document diabetes in the medical record as it will affect the patient’s care plan (www.healthitanswers.net).

When done correctly, HCC coding allows for better patient management and appropriate reimbursement from payers. Expert medical coding services can go a long way in helping providers achieve this goal. Medical coding specialists stay up to date on HCC and best practices and can ensure that the correct diagnosis codes are reported on claims along with complete clinical documentation. Partnering with an expert medical coding service provider can ensure appropriate reimbursement and reduce risk of denials and audits.

Reporting Chronic Conditions in the Age of Value-based Reimbursement

Reporting Chronic Conditions in the Age of Value-based Reimbursement

Chronic ConditionsThe 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:Chronic Conditions Value-based Reimbursement

  • 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.