Walking the Tightrope in HCC Coding

Walking the Tightrope in HCC Coding

The “coding” for HCCs (Hierarchical Condition Categories) is not for the faint of heart. As an outsider or non-coder, looking in, it would appear to be so simple, BUT, It is not simple or easy. No one should do HCC coding without extensive documentation and coding training as well as HCC code capture training – and preferably this person should be a certified coding professional. Nurses, Physicians, and administrative personnel do not have this level of education and training, so they should not be leaned on to act as an expert in HCC code capture compliance, unless they also hold a coding certification

HCC’s are based on patient specific demographics and diagnosis code capture, emphasis on the “diagnosis code capture.” Diagnosis code capture is based on nationally recognized Official Guidelines for Coding and Reporting. . These are published every year and they are an awesome resource for accurate and compliant coding. Also, there is the American Hospital Association (AHA) Coding Clinic for ICD-10-CM. This AHA quarterly publication dates back to 1983 and requires a paid subscription but is also essential for accurate and complaint coding. The Guidelines and Coding Clinic go hand in hand and every coding professional should have access to and utilize these on a regular basis. These two resources provide specific coding guidance for inpatient facility coding, outpatient facility coding, and professional fee coding. Coding in these various settings can be quite different and an experienced HCC coding professional or auditor must be very familiar with these directives going back nearly 40 years.

Even though the Official Guidelines and the Coding Clinic are both amazing resources and invaluable really for compliance, there are still many grey areas in coding that can be up for interpretation. If a coding professional has a question, that is not answered in these resources, they must submit an online question to Coding Clinic for guidance This is especially important if it affects the capture or non-capture of a particular diagnosis code (which drives an HCC, which drives the risk adjustment revenue).  

There are some healthcare practices and organizations that have been in the news regarding their approach to HCC capture. Two areas are of concern: 1) Documentation and 2) Coding Accuracy. “Documentation” means what specifically is written or documented in the medical record from the encounter of care or hospitalization. Only documentation by the following medical professionals is acceptable: MD, DO, PA, NP, and CRNA (there are some exceptions). “Coding Accuracy” means how the coding that is submitted and billed (which in turn is the HCC) is supported within the record and assigned correctly (according to Official Guidelines).

In regards to documentation, the issues in the news are varied, however, one issue in the news is that some organizations are leading and incentivizing providers to over-document and/or adding diagnoses. Also, EMR’s that are only giving options of diagnoses that are HCC’s (when the most common diagnosis is not an HCC), has occurred, such as directing the provider to the diagnosis associated with HCC payment. Another issue is using EMR technology in a creative way in which diagnoses are pulled from one document source and embedded in another such as a clinic note – which then makes it appear that the provider is approving it as a diagnosis that was assessed, treated and/or managed and should be code-able.

Coding accuracy – to perform coding accurately, as stated above, you must utilize a highly skilled and trained HCC coding /auditor professional that is a trusted member of the Team. This individual will play a pivotal role in assuring overall compliance, an accurate interpretation of coding guidelines, documentation, and documentation practices. Organizations must abide by the Official Guidelines, and not assume that skirting the issues, or interpreting a gray documentation or coding area to the benefit of the organization, is compliant.

Compliance involves integrity and assurance of accuracy in submission of diagnostic codes in the risk adjustment models. This is the tightrope – ensuring the there is a balance between ethical and compliant submission of coded data is foremost. Yet striving to capture all the diagnosis codes accurately that reflect the true severity and clinical picture of the patient, based on documentation is also a primary goal and this goal if obtained will result in appropriate and accurate reimbursement.

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