Hierarchical Condition Categories: It’s Not Just for Inpatients

The number of conditions a patient has is now going to factor into the risk adjustment score (RAS).

EDITOR’S NOTE: Dr. Erica Remer reported this story live during the January 21 edition of Talk Ten Tuesdays. The following is an edited transcript of her reporting.

In March, I make my annual pilgrimage to Columbus, Ohio to speak at the Ohio Health Information Management Association (OHIMA) conference, and this year, my remarks are titled, “The HCC Model: Risk Adjustment isn’t just for Inpatients.” You can catch it early if you join me on Jan. 29 on my webinar for ICDUniversity on Wednesday (or on-demand).

In preparation, I scrutinized the 2020 Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Categories (HCC) model. I thought I would share some general pointers with our audience. Interestingly, many of the basic concepts are just as important in the inpatient DRG risk-adjustment model.

The first point is that the number of conditions a patient has is now going to factor into the risk adjustment score (RAS). The RAS will now include the following;

• A baseline score for demographics
• Additional risk adjustment factors for each specific condition after the hierarchy is applied, when applicable
• The adjustment for interactions between certain conditions, like simultaneously having heart failure and chronic kidney disease
• An additional “fudge” factor if the patient has four or more HCC conditions

A pervasive issue noted in the HCC model is the use of a “history of,” a key coding-clinical disconnect. To coders, this phrase means “old,” “resolved,” or “no longer active,” and it often leads to a Z code, which is not risk-adjusting. The clinician may really mean to indicate a chronic or controlled condition that is part of the patient’s medical history.

This may mean the difference between an HCC condition, like chronic pulmonary embolism, with an RAF of 0.383, versus a non-HCC condition, like Z86.711, Personal history of pulmonary embolism. Does “history of lung cancer” mean that the patient has lung cancer that is currently being treated or is not treatable, for a risk adjustment of 1.024? Or does it mean Z85.118, Personal history of other malignant neoplasms of bronchus and lung, which provides no risk adjustment?

The next concept is to designate conditions as being “in remission.” These are conditions that might fall off the provider’s radar if they no longer constitute active medical problems. Conditions like acute leukemia, severe substance use disorder (otherwise known as dependence), or depression, specified as “in remission,” are still housed in the respective HCCs, and reap the associated risk adjustment.

Speaking of which, if your provider documents “depression” without specificity of “recurrent” or “in remission,” and without detailing the severity of the depression, the code assigned is F32.9, Major depressive disorder, single episode, unspecified. This is neither a CC inpatient nor is it included in HCC 59 for the RAF of 0.309.

Linkage is critical to landing in the right HCC. If your provider documents right ankle ulcer on today’s visit, and atherosclerosis two visits ago, the dots can’t be connected to yield atherosclerosis of the extremity with ulceration, even if the coder would compliantly be permitted to do so, per the ICD-10-CM guideline “with” convention, had the diagnoses appeared conjointly in the same encounter. This could mean the difference between an RAF of 1.488 and 0.515.

Medical conditions this year predict expenditures for the following year in the prospective CMS-HCC model, and the slate is wiped clean on Jan. 1. An acute injury or illness counts only for the next year, but chronic conditions remain part of the patient’s risk adjustment for as long as they persist.

Therefore, the problem list must be curated and edited to reflect the accurate capture of the patient’s conditions. If the problem resolves, it should be removed, or it should be relegated to a “personal history of” condition. If it persists, the condition may become a chronic condition, like chronic hepatitis or pancreatitis. An initial encounter may morph into a subsequent or sequela encounter and may land in a different HCC, like head injuries.

Your best bet is to spend some quality time scouring the HCC list as I did. You just may recognize conditions that will make a difference to your clinician, their quality metrics, and their bottom line.

Programming Note:

Listen to Dr. Erica Remer every Tuesday on Talk Ten Tuesdays, 10-10:30 a.m. EST.