Proper HCC coding and documentation is necessary to capture the full complexity of a patient’s condition for higher reimbursement.

1. Ensuring Accurate
HCC Coding and Documentation
Proper HCC coding and documentation is necessary to
capture the full complexity of a patient’s condition for higher
reimbursement.
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2. In 1997, the Centers for Medicare and Medicaid Services (CMS) mandated the Risk
Adjustment and Hierarchical Condition Category coding or HCC coding payment model.
Today, the HCC methodology plays a critical role in the dynamic insurance benefits and
reimbursement scenario. The model assigns a risk factor score to individuals diagnosed with
a serious or chronic illness based on their health conditions and demographics. Accurate
HCC coding and proper documentation to capture the full complexity of a patient’s condition
will result in higher reimbursement.
Success with HCC coding depends on accurate and timely capture of data as well as proper
tracking of a patient's care and condition over time.
A patient’s health conditions are determined by the ICD-10 diagnoses that physicians
submit on claims. HCC codes allow payments to be risk-adjusted based on the complexity of
the patient’s condition. Using a patient’s documented 12-month diagnostic coding history,
the risk adjustment model predicts future financial utilization and risk. Each patient is
assigned a risk score that reflects the complexity of his/her condition. Higher risk scores
represent patients with a higher burden of illness and vice versa.
However, inadequate or incomplete chart documentation and incomplete or inaccurate
diagnosis coding can lead to a lower risk score. Coding properly increases risk adjustment
factor (RAF) scores and improves practice revenue. There are more than 9000 ICD-10 codes
that map to 79 HCC codes in the Risk Adjustment model.
Ensuring proper HCC capture
ICD-10 brought increased code specificity and increased requirements for detailed
documentation. Proper HCC capture means ensuring that claims are submitted with codes
that capture all manifestations of a chronic disease that the patient has.
For instance, using the ICD-10 code 11.9 for all diabetic patients would ensure payment
only for evaluation and management (E/M) visits. If a diabetic patient is also diagnosed with
nephropathy, more specific codes, such as E11.21 (Type 2 diabetes mellitus with diabetic
nephropathy) or E11.22 (Type 2 diabetes mellitus with diabetic chronic kidney disease).
This moves the patient into a higher-risk HCC, which will ensure accurate and adequate
payment based on expected medical costs.
How the Risk Adjustment Model works

3. Importance of proper documentation
CMS expects patients’ conditions to be documented and evaluated each year. The
documentation in the medical record must support the submitted diagnosis. It must provide
evidence of the presence of the condition(s) as well as the health care provider’s
assessment and/or plan for management of the condition.
Documentation should include:
 Patient’s name and date of service (DOS)
 All of the patient’s conditions, including co-existing ones
 Details to code each condition to the highest degree of specificity
 Treatment and/or management for each condition
 Physician’s signature, credentials, and date
The assessment of the patient’s condition must be done at least once every calendar year to
be included in CMS’ risk scoring.
Medical Coding Outsourcing for Accurate HCC Coding
Expert certified coders in medical coding companies work with physicians to address
their HCC coding and documentation challenges. Their support would include:
 Helping providers understand the requirements with codes that are commonly used
 Ensuring that manifestations of certain diseases are not overlooked
 Coding to the highest level of specificity
 Ensuring sufficient and complete clinical documentation in the EHR
 Accurate capture of chronic conditions in compliance with CMS guidelines
 Ensuring that providers assess chronic conditions at least on a yearly basis, so that
all of these conditions can be assigned proper HCC codes Professional medical
coding services ensure compliance with best practices for risk adjustment,
documentation and coding.