Q: “If you have 2 HCC codes in the same category such as 250.40 and 250.50 what is the trumping rule?”
A: This is really funny because I think this might be one of our students who submitted this; I didn’t get to see the name, because I use the word “trump” all the time and I’ve not heard anybody else use that term. Yay, for them, submitting this question!
Actually this code, 250.40 is diabetes with renal manifestations, type II diabetic. What is fantastic about Find-A-Code is they have all of the HCC categories. The past one is 12, 21 and 22. They even have the ESRD and the Rx HCC listed when you go in and looks at that code; so, I really like that. Again, it’s an 18 so we know it’s diabetes with chronic complications is what 250.40 is, a category 18.
When you scroll down and you look at 250.50, it’s the same thing but its ophthalmic manifestation. Well, it’s an 18 also. Now, you can see that previously it was an 18 and unlike the other code. But the codes are all the same, they’re both 18s. So, what do you do in this dilemma?
HCC Coding – Two HCC Codes in the Same Category- Video
Now, as a little bit of a back reference for you, if you don’t know about HCC coding or you’re not one of our students, you are collecting these chronic conditions, like the250.50, and you’re grouping them into the categories and both of those are in the category of 18. Eighteen is the category code that the MA Plans and everybody else is looking for. They don’t look at the diagnosis code. There could be multiple codes that are 18s, that are 22s and 50s and there’s all this different HCC categories, so all of this diabetes with chronic complication codes fall under 18. That has to be captured once a year and there’s more than one pull for this or captures a year; they pull three times a year.
For your patient to project how much money the MA Plan needs to set aside for that patient for the future year in adult based on whether they’re in 18 or whatever category they come in. They don’t care that they have multiple that are in 18, what they care about is do they have an 18, a 20, a 51, or 118 that are all of the 70 categories that could be used.
So, ultimately, if you have two are 18, it doesn’t matter. You just have to capture something that’s in the 18. Now, depending on who you work for as an HCC coder, if you work for the physician’s office, I would say you capture every chronic condition regardless of the category that’s in because it just might end up being that the encounter that you’re submitting for may not be a clean encounter. By that I mean, maybe the signature is not right, or maybe when it’s scanned in to go to the MA Plan, they can’t read the date of service or the patient’s name might not be clear so they can’t count that one.
So, if you send in one encounter and it’s not clear for whatever reason, there are delays and all kinds of problems, so I would say for a physician, they capture everything. Then, when it gets sent to the MA Plan, the MA Plan narrows it down and captures like every six months. So, for the first six months, they’re going to collect as many… they want to get an 18, but they don’t have to do it again for that patient and until the next six months. And then, when it goes off for the review, the funnel is narrowed down even more.
But this is what you’re looking for, is the HCC category. The first level is collecting all the chronic conditions as much as you possibly can and your physician should be listing those and giving lines to show they’re active and they’re actively being treated because you have to have face-to-face visit for those account.
The next level is going to say, “Well, every six months, we need to be able to collect an 18 if that’s what our patient is in that category. And then, again, the funnel changes. But, maybe you’re being told “Only capture one diagnosis in each category,” and you have two to collect, I would go back and see which do I have the most documentation on? Which is it abundantly clear in this encounter that this is a current and being treated diagnosis, chronic condition with everything looking beautiful, from the signature to the line that you can draw seeing that they have ophthalmic issues, that they’ve been referred to a specialist and any medications that they’re taking. That’s the way I would do it. But as a general rule, it doesn’t matter, you just got to get one every year out of your patient to be able to put them in that category to have the money set aside for them.
Excellent question and this is something that’s going to be very prevalent in our future so I’m glad that you asked it so we could talk about it on the webinar, and just because I love HCC as well, it gives me a chance to talk about something I like.