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As we know, Hierarchical Condition Categories (HCCs) are used as a reimbursement methodology, quality measurement, and chronic care monitoring tool in Medicare Advantage and Patient Protection and Affordable Care Act (PPACA) health plans, as well as with some Accountable Care Organizations (ACOs) and other value-based, risk-sharing provider groups.

But for the readers of this article, what is important to know is that HCCs open up opportunities for health information management (HIM) professionals to demonstrate their information management, documentation, and coding skills.

Only 11,000 ICD-10 diagnoses qualify to be categorized as HCCs. Many unspecified codes are excluded. Retrospective coding queries and prospective clinical documentation improvement programs can hone in on associated clinical indicators, but undocumented conditions require further clarification. 

I predict that it won’t be long before many physician practices hire their own clinical documentation improvement (CDI) specialists. That person will need to be both a coding anddocumentation expert. Coders have an excellent career opportunity in the HCC environment, and to those who have an interest in pursuing CDI, don’t let this opportunity pass you by. Now is the time to obtain your certification in documentation improvement; certification options are available from the American Health Information Management Association (AHIMA) and Association of Clinical Documentation Improvement Specialists (ACDIS).

Let’s examine four specific actions HIMers can take to help their providers achieve documentation that supports what services are delivered, potentially improve the reimbursement received, and enhance those public profiles.

1. Examine the providers’ “favorites list.” Often these lists include unspecified general conditions (e.g., congestive heart failure or kidney disease). Adjusting these lists may require some one-on-one education with the provider to explain:

    • Why his or her favorites need to be expanded;
    • How those non-specific conditions may negatively impact their reimbursement and profile in the long run; and
    • If permitted, how to use the electronic health record’s (EHR’s) pick list to select the most specific diagnosis.  

While working with these “favorites lists,” you may see the repeated use of NEC codes. High frequency of NEC codes sends a red flag to the payers. As a preventative measure, run some reports from the billing system now to see how often NEC codes are being used and by whom, and then do a spot check of the documentation for a sample of those cases to see if the NEC code really was correct.

Remember, the coding of NEC conditions may be as much of a documentation issue as it is a coding issue, so some coder re-education may be required.

2. For those payers that are denying, rejecting, and/or requesting copies of records for claims that were submitted with unspecified codes, in addition to querying, consider establishing a hold queue that pends the claims and waits for test results that can either confirm or clarify the conditions being cited.

Yes, it will add a few days to claim submission, but it will also more than offset the time required to deal with a denied or rejected claim and the cost to copy a record.

3. In collaboration with patient billing, watch for denial trends. Track denials by specialty, provider, coder, and payer; and capture the frequency and type of service being denied. Implement process revisions based upon the findings. If you identify a trend or pattern with one or more providers or coders, re-educate.

4. Finally, each year, look at the changes to the HCCs and assess what documentation education may be required for the providers. At the same time, share any changes to the risk adjustment factors with finance so that they can address the fiscal impact.

There are many other opportunities in this environment. So as you promote your skills, you’ll find other avenues to pursue to demonstrate your data analytic and display abilities, the value of your fiscal enhancement input, and your provider partnering talent.

Make this your resolution for 2017!


Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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