Understanding Risk Adjustment: When Capturing HCC's is Not a Part of My Work Flow Understanding Risk Adjustment: When Capturing HCC's is Not a Part of My Work Flow

Understanding Risk Adjustment:
When Capturing HCC’s is Not a Part of My Work Flow

Stephanie Allard, CPC, CEMA, RHIT
Senior Compliance Consultant for DoctorsManagement

This auditing and compliance “Tip of the Week” was originally published by the
National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

Many facilities are forming departments to work on documentation improvement and to properly capture patients’ chronic conditions due to a rising emphasis from CMS on quality of care and prevention. Through Risk Adjustment and Hierarchical Condition Coding (HCC), CMS offers additional reimbursement to managed care plans based on the risk factor of the patients they are covering within their health plans. What is Risk Adjustment and Hierarchical Condition Coding (HCC)? And how does this effect your work flow if you are not directly a part of this process within your facility?

What is HCC? In summary, CMS has categorized conditions into clinical and financial groups with some conditions being weighted more than others. Each condition has an individual score attached to it and the conditions that a single patient has are factored together and an overall risk factor score is assigned based on CMS’s categories and hierarchy. The risk adjusted score determines the reimbursement the advantage plan will receive from CMS. There are different models that CMS uses to identify the conditions and specific ICD-10 diagnoses that they will reimburse.

Overall, HCC reimbursements have a trickle-down effect as they are not paid out directly to the facility and providers. Instead it is the advantage plans that receive the additional reimbursement and the advantage plans that are ultimately responsible for the data that is being reported to CMS.

As auditors, how does this affect our daily work? While it is not our physicians and providers that are receiving the direct reimbursement from CMS, it is their documentation that must properly support the conditions being reported by the advantage plans. As auditors, we are reviewing the work of our providers on a daily basis and if our facility is capturing HCC’s we need to be aware of what HCC is and what the documentation requirements are.

It is important to review your individual advantage plan guidelines as they at times can be more conservative than CMS guidance as the accuracy of diagnosis submission is of high importance. Within this article we will discuss the methods based on CMS guidance.

In order for documentation to support risk adjusted diagnoses, the provider must document the patient’s chronic conditions that are currently active or that are a part of their past history and are still relevant to their care. All diagnoses reported must have MEAT to be considered acceptable for risk adjustment. The acronym MEAT stands for Monitor, Evaluate, Assess/Address and Treat. Just documenting that the patient has a condition or past history is not sufficient. The documentation must show the providers current involvement in the care of the condition(s) and that is shown through their assessment and plan using the concept of MEAT.

In addition to documentation requirements, the following are also requirements for the capturing of risk adjusted codes:

  • Documentation must be a result of a face-to-face visit (with the exception of pathology professional component only)
  • Acceptable sources of documentation include hospital inpatient and outpatient facilities and physicians
    • CMS has a table that outlines the acceptable physician specialty types (see pg. 46 of resource at bottom of article)
  • ICD-10 codes must be supported by coding guidelines
  • Conditions must be documented and supported by MEAT at least once for each calendar year
    • This means that the supporting documentation does not carry over year to year
    • On January 1 of every year the slate is wiped clean and the providers must support the conditions all over again at least one time for the new calendar year

Depending on the structure of your HIM departments, you may not be working within a risk adjustment team capturing the codes, but if your facility is focusing on capturing risk adjusted codes all of the departments related to documentation and coding can work together to improve the process and supporting documentation. When all of the staff involved in documentation improvement regardless of their end focus work together the providers will receive uniform feedback and the advantage plans will be able to capture and report conditions that most appropriately reflect the patient’s risk.



What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email info@drsmgmt.com.
  2. Read more: What can you expect from a coding and compliance review?
Here’s why thousands of providers trust DoctorsManagement to help improve their coding and documentation.

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Proprietary risk-assessment technology – our auditing team uses ComplianceRiskAnalyzer(CRA)®, a sophisticated analytics solution that assesses critical risk areas. It enables our auditors to precisely select encounters that pose the greatest risk of triggering an audit so that they can be reviewed and the risk can be mitigated.

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