CMS Hierarchical Condition Categories through a different lens

Wahiyda Harding MSA, RHIA, CCS
Education and Training Mentor 
MedPartners | MPU Division

Hierarchical Condition Categories (HCCs) were first implemented by the Centers for Medicare and Medicaid Services (CMS) in 2004 as a payment model that adjusts for risk of mortality (ROI) and severity of illness (SOI). The risk adjustment (RA) should demonstrate the patient’s acuity. HCCs impact quality and reimbursement.

When coding inpatient records, from a financial perspective, the coder looks for comorbid conditions (CCs) and/or major comorbid conditions (MCCs) to ensure that they are coded. This practice often leads to missed opportunities as a lot of HCCs are not CCs or MCCs, according to the MS-DRG system. It is important to report all conditions per coding guidelines and to confirm that the patients’ true clinical picture is detailed based on the codes reported. Diagnoses are not reported sometimes, as they do not have an impact on the inpatient DRG financially.

HCCs do impact the facility financially with quality measures, accountable care organization (ACOs), shared savings programs, value based purchasing, and through risk adjustment. They do not directly impact the DRG for the patient. Multiple HCCs can be captured per encounter and the coded data should tell the patients’ story, clinically.

Medpartners’ Clinical Documentation Improvement (CDI) provides training and education to improve provider documentation. The documentation improvement team works with the provider to improve the documentation in the patients’ medical record. The complete clinical documentation improves diagnosis coding to the highest level of specificity.  For example, diabetes mellitus unspecified, (HCC 19 has a risk adjustment factor (RAF) score of .104) while diabetes mellitus with proliferative retinopathy and macula edema right eye has, (HCC 18 RAF score of .318 and HCC 122 RAF .127) (FY 2018)

The CDI concurrent review focus is not solely on improving the MS-DRG but improving the overall documentation with a higher level of diagnosis specificity. This approach minimizes the need for requesting retro queries for provider clarification. The focus is on the completeness of the documentation for each patient, regardless of which one improves the MS-DRG; often incorporating specificity queries. The burden is placed on the provider to document all conditions both acute and chronic to the highest level of specificity for the complete clinical picture. This allows improved accuracy of the patient RAF’s score in the diagnosis code reporting. Finally, having knowledgeable medical coders that understand HCC will guarantee appropriate diagnosis codes are reported based on the complete clinical documentation.

Another way to improve appropriate documentation capture is by focusing on the Electronic Health Record (EHR), and creating more specific options in the alerts or prompts to help providers accurately and completely document the patients’ diagnoses. The team focuses on conducting education on best practices for documentation and make changes based on the trends and/or needs. Every diagnoses must be monitored, evaluated, assessed and treated to meet the reporting criteria.

There are four new risk generating HCCs for fiscal year 2019. Three of which are related to substance abuse and mental health (HCC 56, 58, 60). According to an article published by the National Institute on Drug Abuse, there is an opioid epidemic and an increase in Americans addicted to pain killers; which can explain these 3 new HCC categories.

MedPartners has qualified and experienced CDI and HIM professionals to available to fill your facilities coding and documentation improvement needs and assist with capturing CMS-HCCs. Contact MedPartners today and let us help you with your staffing needs.

For more information on the impact of the Opioid epidemic check out the article below:


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