Medical practices participating in Accountable Care Organizations, Advanced Payment Models or risk based commercial contracts need to understand Hierarchical Condition Category (HCC) coding. While most claims continue to be paid based on the CPT code, future payments, bonuses and even capitated payments under value based systems will be determined in part by the acuity of medical practices’ patients.
How does a payer know how complex the practices’ patients are? By the diagnosis codes submitted on claim forms by medical practices and other health care professionals. The payer calculates a risk score based on the patient’s conditions, and calculates an aggregate risk score for a panel of patients.
Diagnosis isn’t just for medical necessity any more, but determines the calculation of risk scores. Practices need to understand how risk adjusted scores work. They need to comply with ICD-10 rules related to assigning diagnosis codes in order to avoid errors in diagnosis coding. There are diagnosis-coding errors that reduce risk scores, by underreporting severity for chronic and acute conditions. There are diagnosis-coding errors that incorrectly increase risk scores, by reporting “history” conditions as current conditions and selecting diseases and conditions that weren’t addressed at the visit. There are a few status codes that have a risk adjusted factor, and practices need to identify these and use them, when appropriate.
This webinar will describe the key concepts of HCC diagnosis coding and ICD-10 rules that must be followed in selecting diagnosis codes. It will also illustrate a process for assessing diagnosis coding and present common clinical examples.
After this session, participants will be able to:
Understand the key concepts of risk adjusted diagnosis coding
Assess the accuracy of their own diagnosis coding
Select conditions for review and education, based on frequency