What Is Risk Adjustment?
Risk adjustment methodology accounts for known and discovered heath data elements and compares levels of wellness among patients. The accurate selection of diagnosis codes plays a vital role in all risk adjust models. With the increase of Medicare Advantage plans and inclusion of risk adjustment models in the ACA, proficiency in selecting diagnosis codes and how it relates to risk adjustment models including Hierarchical Condition Categories (HCC), Chronic Illness and Disability Payment Systems (CDPS), and blended models is a valuable skill. Source: https://www.aapc.com/training/online-risk-adjustment-training.aspx
HCC Coding Definition
Hierarchical Condition Category (HCC) is a risk adjustment model implemented by CMS in 2004 to estimate predicted costs for Medicare beneficiaries based on disease and demographic risk factors or simply, the category of medical conditions that map to a corresponding group of ICD-9 diagnosis codes. The number of HCCs and affected ICD-9 codes can change from year to year and with the implementation of ICD-10, it will significantly impact the number of HCCs and the number of diagnosis codes currently in effect. There are approximately 87 risk score categories which map to over 3,000 different ICD-9 codes. In order to accurately reflect a patient’s risk profile, it requires more than the standard ICD-9-CM codes commonly seen in current billing practices. Source: http://www.advantageplan.com/wp-content/uploads/ADV-HCC-Presentation_Final_111114AB.pdf
What Is HCC Coding – Video
Few HCC Coding Guidelines & Tips
1. As a medical group or independent practice association, you are most likely sending data electronically to your contracted health plans. If you are using an electronic data interchange (EDI) vendor, have a discussion with them to make certain you receive reports on rejected items. Also ask them to verify the maximum number of diagnosis codes they capture and transmit to your health plans. You may be able to locate diagnosis codes, otherwise lost, that will positively affect your revenue.
2. Find out if new patients already have assigned HCCs from their prior health plan. If so, be sure that you maintain those (if appropriate) moving forward. Doing so will assist with both continuity of care and comprehensive data collection.
3. Chart reviews offer great opportunities for in-service education or even the creation of educational materials. If your chart review uncovers common documentation errors, use this as an opportunity to develop training guides or even one-on-one training with physicians and office staff. In short, don’t think of chart reviews as an end, but rather a beginning.
4. New tools on the market make it easier than ever to track diagnosis data for terminated patients. Revenue can be re-captured for members that may have initially appeared on your monthly eligibility reports, but no longer appear because the member’s eligibility has ended. This is one of the most common areas for lost revenue and one that is worth renewed focus.
HCC Coding Training
Certification Coaching Organization (CCO) is offering an online HCC Coding Training Course/Risk Adjustment Training currently. With limited education available for coders seeking risk adjustment coding skills, this course so valuable. Whether you are an experienced coder in risk adjustment or seeking better understanding, this course will take you through the fundamental principles underlying risk adjustment coding and prepare you for the CRC exam.
The CCO’s HCC coding training will:
- Discuss the different risk adjustment models (HCC, CDPS) and guiding principles of Risk Adjustment
- Identify the impact diagnosis coding has on risk adjustment models
- Evaluate the elements of the medical record used for diagnosis code selection
- Review Official Guidelines for Coding and Reporting for ICD-9-CM and ICD-10-CM
- Risk Adjustment Terminology
- HCC Coding Hierarchy Methodology and Guidelines
- HCC Disease Co-morbidity and Interactions
- Bulletproof Documentation with Linking Statements
- Understanding The Risk Adjustment Submission
- Prospective, Retrospective Reviews
- Risk Adjustment Factor Scores (RAF)
- Benefits of the Annual Wellness Visit (AWV)
- Suspect Generation and Predictive Modeling
- Medical Loss Ratio Reports (MLR)
- Healthcare Effectiveness Data and Information Set (HEDIS)
- Five-Star Quality Rating System (STAR)
- Model Output Report (MOR file)
- Risk Adjustment Data Validation (RADV)
- ICD-10-CM Impact on HCC Coding and Risk Adjustment
- HCC Job Search Tips
Related HCC Coding Posts:
- Risk Adjustment Coding Online Training
- HCC Medical Coding – Medicare Advantage to the Physicians – Video
- HCC Medical Coding Risk Adjustment Training – Video
- HCC Coding Training – Introduction to Risk Adjustment
- Medical Coding Jobs for HCC new Coders and Auditors -Video