8/28/2017 Operationalizing Hierarchical Condition Categories (HCC Scoring) Rhonda Quast Director of Revenue Cycle rquast@eidebailly.com 701.476.8360 Objectives • Define Hierarchical Condition Categories • Determine why they are important to your organization • Understand common errors that can affect HCC scores • Discuss how you can operationalize processes to support accurate HCC scoring in your organization www.e ide ba i l l y . co m 1
8/28/2017 Hierarchical Condition Categories • The CMS-HCC model was first introduced to pay Medicare Advantage plans • Risk-adjustment model which calculates expected resource use of a patient or patient population • Utilized to communicate expected and current cost and resource utilization at a patient level Source: CMS www.e ide ba i l l y . co m HCC Scoring Diagnosis Codes Community or Gender Institutional HCC Dual Reason for Enrollment Eligibility Age www.e ide ba i l l y . co m 2
8/28/2017 HCC Scoring 79 Categories www.e ide ba i l l y . co m Categories • Over 8,500 ICD-10 Diagnosis codes are broken down into 79 categories • Not all ICD-10 codes are mapped to a category. Only diagnosis codes that are usable in predicting costs are included. • Categories are comprised of diagnoses that: • Are clinically related • Have similar cost/resource use expectations www.e ide ba i l l y . co m 3
8/28/2017 Example of Categories Category • Description HCC 17 • Diabetes with Acute Complications HCC 18 • Diabetes with Chronic Complications HCC 19 • Diabetes without Complications www.e ide ba i l l y . co m HCC Scoring 79 Categories 31 Hierarchies www.e ide ba i l l y . co m 4
8/28/2017 Hierarchies • CMS developed 31 hierarchies of the 79 categories • These hierarchies allow for risk calculation to occur from the most severe diagnosis when a lesser diagnosis is also submitted in the same year www.e ide ba i l l y . co m Example of a Hierarchy E0821 – E0811 – HCC 18 HCC 17 E119 – Type 2 HCC 19 Diabetes Diabetes Diabetes Mellitus due to Mellitus due to Mellitus underlying underlying without condition with condition with complications diabetic ketoacidosis neuropathy with coma www.e ide ba i l l y . co m 5
8/28/2017 HCC Scoring 79 Categories 31 Hierarchies Disease Interactions www.e ide ba i l l y . co m Disease Interactions • Disease interactions are used to represent the additional resources utilized for certain conditions when a patient endures them in combination with each other • They also represent a higher cost utilization for some diseases when a patient is also disabled www.e ide ba i l l y . co m 6
8/28/2017 Disease/Disabled Interactions +.27 +.0608 I110 – Hypertensive Heart Disease Disabled w/ heart failure .323 L89024 – N184 – Chronic Pressure Ulcer Kidney Disease, of Left elbow, Stage 4 .237 Stage 4 2.163 www.e ide ba i l l y . co m HCC Scoring Acceptable Provider Acceptable Provider Settings for CMS HCCs – Settings for CMS-HCCs – Inpatient & Outpatient Outpatient Services Only Services • Short Term Hospitals • Rural Health Clinic (Free- (general and specialty) Standing and Provider- Based • Critical Access Hospitals • Federally Qualified Health • Children’s Hospitals Centers • Long-Term Hospitals • Community Mental Health • Rehabilitation Hospitals Centers • Psychiatric Hospitals • Religious Non-Medical Health Care Institutions www.e ide ba i l l y . co m 7
8/28/2017 HCC Scoring Non-Covered Settings Non-Covered Services • Hospital Inpatient Swing • Ambulance Beds • Lab • Skilled Nursing Facilities • Radiology • Intermediate Care Facilities • DME – Prosthetics & • Respite Care Orthotics and Supplies • Free-standing Ambulatory Surgery Centers • Hospice • Home Health Care • Free-standing Renal Dialysis Facilities www.e ide ba i l l y . co m Approved Providers • Family Practice • Pain Management • Internal Medicine • Interventional Radiology • General Surgery • Nuclear Medicine • Cardiology • Certified Nurse Midwife • Neurology • Optometrist • Pulmonology • Pathology • Nephrology • CRNA • Physical Medicine & • Audiology Rehab • Speech Therapy • Emergency Medicine • Physical Therapy • Ophthalmology • Occupational Therapy • Psychiatry • Licensed Clinical Social • Oncology Worker • Hematology www.e ide ba i l l y . co m 8
8/28/2017 The Clean Slate – January 1st Source: Conversation.com www.e ide ba i l l y . co m Example of HCC Scoring 72 year old male, residing in Nursing Home, presents feeling short of breath. Complains of dyspnea, fatigue, and persistent coughing. Recently completed antibiotics for UTI. U/A done today is clear. Patient appears frail with mild malnutrition. Previously diagnosed COPD, stable on Flovent daily. Patient continues to smoke. After Radiologic exam, patient diagnosed with aspiration pneumonia and sepsis. Antibiotic prescribed twice daily for next seven days. Ensure twice daily on a continual basis. • 72 yo • 72 yo institutionalized • 72 yo male: 1.323 institutionalized institutionalized Poor Coding Better Coding Complete Coding • Aspiration Pneumonia male:1.323 male: 1.323 J69.0: .067 • Aspiration • Pneumonia • COPD J449: .305 Pneumonia coded as J18.9: • Tobacco Use F17.210: 0 J69.0: .067 0 • Sepsis A41.9: .346 • Tobacco Use • Total HCC score: • Mild Malnutrition E44.1: F17.210: 0 1.323 .260 • Total Cost: • Total HCC score: • Disease Interaction COPD*Aspiration $12,152.14 1.39 Pneumonia: .254 • Total Cost: • Disease Interaction $12,767.55 Sepsis*Aspiration Pneumonia: .321 • Total HCC score: 2.876 • Total Cost: $26,416.89 www.e ide ba i l l y . co m 18 9
8/28/2017 Programs that utilize HCC Scoring Medicare Shared Savings Programs Determining Benchmarks Shared Savings/Loss Calculation www.e ide ba i l l y . co m 10
8/28/2017 Medicare Advantage PMPM HCC Score Payment www.e ide ba i l l y . co m CPC+ Source: CMS www.e ide ba i l l y . co m 11
8/28/2017 MACRA Previous Models (Value Based Modifier) Cost Category New Modifiers/Groupers www.e ide ba i l l y . co m New Required Modifiers and Codes • Care Episode Groups • Patient Condition Groups • Patient Relationship Categories www.healthinformatics.wikispaces.com Source: CMS www.e ide ba i l l y . co m 12
8/28/2017 Patient Relationship Categories • Patient Relationship codes will be required to be submitted on all claims where a clinician has provided items or services • Utilized to attribute patients, in part or in whole, to clinicians and conduct an analysis of resource use based on care episode and attributed clinician Source: CMS www.e ide ba i l l y . co m Cost: Episode Grouping www.e ide ba i l l y . co m 26 13
8/28/2017 Care Episode Groups • MACRA requires a concurrent approach that enables physicians to determine, at the time a service is rendered, the care episode or episodes to which the service should be assigned based on the goal of the service and its relationship to other services that the patient is receiving • define the types of procedures or services furnished for particular clinical conditions or diagnoses • Enable better measures of the kinds of services and costs physicians can control or influence than the total cost of care and episode spending measures currently in use in Medicare programs • Used to determine resource use by physician groups • CMS must consider the patient’s clinical problems at the time items and services are furnished during an episode of care, such as clinical conditions or diagnoses, whether or not hospitalization occurs, and the principal procedures or services furnished Source: CHQPR and CMS www.e ide ba i l l y . co m Episode Groups • Objectives of their use • Describe or account for Medicare cost and utilization using categories that make sense to clinicians and others who are responsible for patient care and healthcare systems • Estimate average Medicare payments for episodes, risk-adjusted according to patient- level information and other factors as appropriate • Frame spending patterns in ways that highlight opportunities for improvement Source: CMS www.e ide ba i l l y . co m 14
8/28/2017 Patient Condition Groups • CMS must consider the patient’s clinical history at the time of a medical visit, such as the patient’s combination of chronic conditions, current health status, and recent significant history (such as hospitalization and major surgery during a previous period) Source: CMS www.e ide ba i l l y . co m Timeline April 10, 2017 December 14, January 1, 2017 2018 • Final Patient • Final Care • Care Relationship Episode and Episode, Categories Patient Patient and Codes Condition Condition will be Groups and and Patient published Codes will Relationship be published Categories and Codes required on claims Source: CMS www.e ide ba i l l y . co m 15
8/28/2017 Where does Risk Adjustment fit in? Source: progressive-Charlestown.blogspot.com www.e ide ba i l l y . co m Operationalizing HCC Scoring 16
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