HCC (medical acronym for Hierarchical Condition Category) codes offer a holistic approach to understanding the complexity of a patient’s overall healthcare needs – and enable risk adjustment. But with 115 categories in the latest CMS-HCC model, it can feel impossible to avoid errors where diagnoses are miscategorized – which is why an HCC category list is so important.
This list will help value-based care (VBC) providers create accurate coding and ensure they are compensated based on the complexity of the care given to patients.
HCC diagnosis codes are organized to capture the complexity of a patient’s condition. Diagnoses are sorted into relevant categories in order to simplify the coding processes. For example, “Diabetes with Chronic Complications” and “Diabetes with Severe Acute Complications” share the same HCC code – and these are linked to ICD-10 diagnosis codes in order to assign each patient a risk score during risk adjustment.
ICD-10 refers to the tenth edition of the International Classification of Diseases, a medical coding system designed by the World Health Organization to catalog health conditions into groups of similar diseases.
The list of ICD-10 codes is extensive, and select subsets directly relate to specific HCCs. Understanding this relationship is crucial for accurate coding and representation of patient health.
It’s important to note that within this system, the term ‘hierarchical’ implies that certain conditions are ranked in order of clinical significance and cost. If a patient has multiple conditions, only the most severe (as deemed by the hierarchy) is selected for risk adjustment. For instance, a patient with both uncomplicated diabetes and end-stage renal disease would be assigned the HCC code for the latter because it’s considered more clinically significant and resource-intensive.
By acquainting yourself with these hierarchies and their implications, you can ensure that the coding process remains robust, transparent, and truly reflective of your patient’s health profile. Familiarizing yourself with common HCC diagnosis codes will streamline your documentation process, leading to more accurate billing, improved patient care, and faster reimbursements.
Medicare Advantage (MA) is significant in the conversation revolving around risk-adjusted coding models. As per the latest data from the Centers for Medicare and Medicaid Services (CMS), by July 2022, 29.6 million people were enrolled in MA plans. This figure represents nearly 45% of all those on Medicare.
The HCC mapping list, which aligns specific diagnoses with risk adjustment score categories, is not static. The Department of Health and Human Services (HHS) and CMS review and adjust this list to account for updates in ICD-10-CM codes and which subset codes fall under which categories.
Some versions of the HCC list might be relevant for multiple years, while others might see more frequent updates. Healthcare organizations need to ensure that their employees who work in this area of medical coding have the most current and appropriate version of the HCC list.
It’s worth mentioning the number of ICD-10-CM codes to put it into perspective. There are more than 72,000 codes, but only 10,981 fall within the current eighty-six HCCs used in the payment model. In 2024, the number of HCC categories will increase to 115.
A significant chunk of these categories (sixty-seven of the current eight-six) deal with chronic conditions. A chronic condition is medically recognized as unlikely to resolve naturally and to be a condition that requires continuous monitoring.
While we don’t expect HCC coders to know every single diagnosis code by heart, it’s essential to familiarize oneself with the more frequently used HCC categories. The top HCC categories include conditions such as arrhythmias, amputations, common cancers (e.g., breast and prostate), severe obesity, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus in all forms, and major depressive disorder.
Neglecting or inaccurately coding HCC diagnoses can have significant clinical and financial implications. From a clinical standpoint, a comprehensive understanding of a patient’s health status may be compromised if essential diagnoses are overlooked. This could lead to suboptimal care decisions, affecting patient outcomes in both the short-term and in the long run.
Financially, the consequences can be substantial for healthcare providers and institutions. Under MA plans, reimbursement rates are intricately linked to the risk scores derived from HCC coding. Misrepresenting or omitting a patient’s condition could lead to decreased reimbursements, adversely affecting the financial health of a healthcare organization.
Consistent and accurate HCC coding helps ensure that healthcare providers are adequately compensated for the complexity and intensity of care provided. It balances the playing field, allowing resources to be allocated appropriately based on the health needs of the population served.
For healthcare organizations participating in value-based care models, accurately capturing HCC diagnoses is even more critical. It plays a central role in quality reporting and achieving performance benchmarks. Inaccuracies can jeopardize financial reimbursements and impact an organization’s reputation in terms of quality scores and patient outcomes.
Understanding your patients’ needs goes beyond just medical codes–it’s about creating a complete, nuanced portrait of their overall health. With Inferscience as your technology partner, you can leverage their expertise and analysis tools needed to make informed decisions in a value-based care environment. Book a demo today.
