HCC scores have been used since 2004 by Medicare to adjust payments based on the risk level of the enrollee. This has resulted in Medicare paying a higher monthly capitation fee for patients with higher HCC scores as these patients require more resources and disease intervention. The HCC payment system uses ICD-10 codes and demographics to generate a risk adjustment factor (RAF) score which identifies patients that require higher cost to care for and is based on the diagnosis codes billed in the previous review period. Thus it is imperative that proper HCC coding and documentation is critical in ACOs, MA and HVBP. In order to ensure HCC codes and documentation compliance, CMS checks health plans with targeted and random audits. Healthcare providers need to be aware of the essentials required on medical records to mitigate the risk of audits and stay compliant.
To ensure that diagnosis captures the accurate HCC code, healthcare providers should adhere to the M.E.A.T criteria. M.E.A.T stands for monitoring, evaluating, assessing and treatment and is one of the most critical and basic requirements of proper and compliant documentation. M.E.A.T is defined as:
- Monitor: signs, symptoms, disease progression, and disease regression
- Evaluate: test results, medication effectiveness, and response to treatment
- Assess: ordering tests, discussion, review records, and counseling
- Treat: medications, therapies, and other modalities
Documentation without M.E.A.T. to substantiate the diagnosis is likely to be rejected by CMS due to lack of evidence. To adhere to M.E.A.T., providers should:
- Evaluate and document all conditions during each encounter
- Ensure a proper progress note with the HPI, physical exam and medical decision-making process.
- Document each diagnosis in an assessment and care plan
- Ensure that each diagnosis provides evidence that the provider is monitoring, evaluating, assessing and treating the condition.
These four factors establish the presence of a diagnosis during an encounter and ensure proper documentation.
Healthcare providers would do well to remember the following:
- Code to the highest level of specificity
- Maintain HCCs from a prior health plan if relevant
- Ensure comprehensive documentation:
- Perform chart reviews
- Ensure consistent HCC capture
- Stay up-to-date on coding
ICD-10 demands increased specificity and healthcare providers need to stay updated about ICD codes, the changes in CMS’s risk adjustment model, HCC coding and crosswalks, and audit procedures. While physician and other healthcare providers can document the services performed accurately, legibly and completely, collaborating with the right medical coding company with experience in HCC coding will ensure accurate code assignment and proper reporting of diagnoses and procedures, minimize compliance risks and enhance care delivery.
Collaborating with MedConverge will help healthcare providers to
- Take advantage of Medicare risk adjustment coding opportunities by capturing the most appropriate HCC codes
- Ensure that all HCC codes reported on the encounter claim are supported by M.E.A.T.
- Ensure accurate quality measures
- Boost their financial integrity
Our AAPC-certified coders are educated on HCCs and up to date on best practices. We work with healthcare providers to ensure reporting of appropriate diagnosis codes along with complete clinical documentation thus adhering to M.E.A.T. criteria and specificity in coding – thus significantly improving your practice reimbursement under the new payment models.
- CLEMENTS, J. (2017, April 21). HCC Coding-Steps to Maximize Practice Reimbursement. Retrieved August 15, 2017, from www.outsourcestrategies.com: http://www.outsourcestrategies.com/blog/2017/04/hcc-coding-steps-to-maximize-practice-reimbursement.html
- KIERNAN, M. (2017, April 24). M.E.A.T. is at the Heart of HCC Coding and Clinical Documentation. Retrieved August 15, 2017, from www.outsourcestrategies.com: http://www.outsourcestrategies.com/blog/2017/04/m-e-a-t-is-at-the-heart-of-hcc-coding-and-clinical-documentation.html
- Risk Adjustment and Hierarchical Condition Category Coding. (2017). Retrieved August 15, 2017, from www.securityhealth.org: https://www.securityhealth.org/provider-manual/shared-content/claims-processing-policies-and-procedures/risk-adjustment—hcc-coding
- Vegter, K. (2016, August 18). WHAT IS HCC CODING? UNDERSTANDING TODAY’S RISK ADJUSTMENT MODEL. Retrieved August 15, 2017, from www.medirevv.com: https://www.medirevv.com/blog/what-is-hcc-coding-understanding-todays-risk-adjustment-model