The goal when it comes to coding, says physician-blogger Erica E. Remer, should be “to see that the patient looks as sick in the medical record as he or she does in real life.” If you don’t make it clear how sick a patient really is, chances are you’ll end up leaving money on the table.
That’s why it’s crucial to understand and leverage hierarchical condition categories (HCCs) and the codes that allow providers to be appropriately reimbursed for all diagnoses for which a patient is being treated, assessed, evaluated and monitored.
In fact, one of the easiest ways to make sure you always get the maximum appropriate reimbursement is to remember that it’s crucial to always get to the “MEAT” of the matter. The acronym stands for monitor, evaluate, assess and treat, and refers to all chronic conditions that providers need to consider regarding the medical decisions they make and the services they provide.
To be reimbursed at the highest appropriate level, providers must report all diagnoses that impact evaluation, care and treatment. These include all treatments, and coexisting and chronic conditions.
And coders must rely on physicians to properly document critical information. For example, if a lab test shows that a patient with diabetes has high blood sugar, but the physician doesn’t note it on the patient’s chart, there’s nothing the coder can do. Conditions can only be coded from the physician’s documentation, not from lab tests.
Providers must also establish direct correlations between conditions and their complications or manifestations, by using phrases like “due to,” “caused by,” or “secondary to.” For example, a patient with diabetes may be said to have “stage IV chronic kidney disease due todiabetes.” Of note, patients should be described as having a “history of” a given condition only if that condition has already been resolved.
Another complicating factor is that patients may be assigned more than one HCC if a combination of demographics and risk factors add up to more than one kind of chronic illness. Either way, physicians must document HCCs in detail every year. That way, as diseases progress and associated services increase, revenue should increase correspondingly. HCCs exist, after all, to ensure that money is earmarked for patients’ future medical needs.
Nor should physicians rely on the word of patients, of course. A patient taking medications to control chronic high blood pressure and high cholesterol may not think of those as chronic conditions when asked about his or her medical history.
Taken as a whole, understanding HCCs is a challenging but crucial part of coding, especially as services transition to value-based contracts and reimbursements. Thankfully, help is available.
CareThrough Navigators know how to update EHRs to reflect the most accurate HCCs, coexisting conditions and population health trends. When navigators are embedded within your care team, they can also ensure that your high-risk patients are seen at least once every calendar year. They keep you up to date with complications that occur between visits, they set referral appointments and preventative screenings, and they identify “rising risk” patients.
QueueLogix offers a cloud-based software platform to help ensure that all conditions are fully documented, all risk scores are accurate, and all billing is complete. QueueLogix software is designed to increase accuracy, reduce denials, submit correct ICD-10 codes for each chronic condition, drive reimbursement, and increase visibility and communication with providers. After all, the ability to code for complexity is the key to maximizing reimbursements with HCCs.
Trained medical scribes from ScribeAmerica help capture needed specificity in real time while physicians are conferring with patients. By providing critical support, they help ensure that physicians accurately document every encounter in EHRs and that all conditions are monitored, evaluated, addressed and treated (the “meat” that supports HCC codes). ScribeAmerica training emphasizes risk-assessment and HCC accuracy, with the goal of documenting for the highest disease specificity. In fact, many scribes are eager to learn more about disease acuity, because they hope to have careers in medicine someday. They can help paint the required detailed picture of the patient’s full disease burden, and how each separate condition is being managed—in other words, exactly what’s needed for optimal reimbursement.