HCC Coding and Documentation: A Doctor's View
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Do you know when CMS will release ICD10 HCC codes?
I cannot find anything on their website about it.
They have not released it yet nor have they announced
when they are going to release the mapping
Is there a time limit attached to cancer dx coding - for
example, when do you code history of cancer vs cancer??
Patient has breast cancer but has masectomy - next year's
office visit is it history of cancer if no treatment is being
done for breast cancer?
The rules are the same in this model. If the patient is
currently being treated for their cancer, then they still have
it and the diagnosis should be made. By coding rules, if
they are on Tamoxifen for treatment, they have Breast
Cancer as long as they are on the medicine. When they
quit, they are then HISTORY OF
Is this already being implemented? or is there a start date?
Medicare Part C (the HCC model) is currently underway.
There was a phase in period that ended in 2007 but it is
fully up and going now.
That is an unfortuante typo error. Thank you for pointing it
out.
What model are you using for this presenation? COPD is
HCC 108 in Part C. COPD is HCC 108, not 96. Thanks.
Do you know where you can get the Risk Adjusment
Timetable. I have one but the dates of submission will run
out soon. I looked on the MC website but could not find
it.
Will you be addressing the V22 model?
The slides I am showing come from the website where I
downloaded the training manual. I cannot specifically
remember how I found it but I believe if you search
"REGIONAL TRAINING" it will guide you to the manual
and power point slides.
I'm not sure what model you are referring to. There is the
ESRD model, the HCC model (Part C) and the Drug model
(Part D)
So would the DM with opthy dx need 2 codes still? even ICD-10 combines the codes so just the one appropriate ICDthough ICD 10 includes that in the code do they still need 10 code will suffice. Until I-10 comes, two codes are
the complication codes?
necessary.
Can you use RN or MA gathered information such as past
medical, family & social history, and review of systems to
support the ICD9 codes that are submitted for risk
adjustment?
There must be specific documentation attributed by the
Medicare Approved provider. Any information that can be
used in the E&M code also counts for the diagnosis capture
but it is best if the clinician specifically mentions it.
Different auditors have differing opinions on that gray area.
It is more likely to pass an audit if there is documentation
in the physicians history and or exam as well as in the
Assessment portion of the note.
Can a resident, who has an MD title, provide the sole
documentation to support HCC submission or does there
have to be additional documentation by an attending to
support?
COPD is now HCC 111 for 2013 dates of service and was
HCC 108 last year so I am not sure where got the
information that it was HCC 96. It has never been HCC 96.
YES - it is the credentials of the individual provider that
Medicare looks at.
Is his in writing somewhere? my employer is telling us
coder educators to have providers still submit the
complication code in ICD 10... I know I will have kick
back if the ICD10 descriptor is inclusive to the
complication why would they need to code the additional
code please advise
No one is using ICD-10 now. I must be confused on the
question. If you are speaking about post ICD-10
implementation, everyone will obviously have to follow the
ICD-10 conventions.
It was an unfortunate typo. Thank you for being so diligent
and pointing that out. I have given this presentation before
and no one else caught it. Thanks
If you are healthy you should then pay a lower premium,
right?
No. They are unrelated. The HCC model deals more with
payment to the insurers rather than the premiums you pay.
The patients sign up for their Gold, Silver, Bronze plan and
they are not directly impacted by their health status. The
HCC model is a back end function to pay/reward plans that
take care of sicker people.
CMS covers incident to services provided by an RN, when
specific criteria are met. Given this, can an RN incident to
service documentatin be used to support a HCC
submission?
Incident To doesn't qualify as it is a face to face visit done
by the RN. It really shouldn't matter in the long run as in
order to bill for Incident To, that means the doc has already
made the diagnosis that year, documented in the chart a
care plan and sent the patient to the ancillary staff to render
the care. Therefore, you should use the doctor's note to
validate the diagnosis if audited rather than the RN,
incident to, note.
If you are diagnosing metastatic cancer does it have to be
established histologically to prove it's not 2 separate
instances of cancer?
There does not have to be histological proof to make the
assessment of metastic cancer. If someone has lung cancer
and a mass shows up in the liver, if the doc states it is now
lung cancer with mets to the liver, that will suffice. It
would be an unnecessary procedure to do a liver bx for the
sake of reimbursement.
Can documentation from a procedure such as an
echocardiogram or cardiac cath be used to support an
HCC? if the provider is present with the patient during the
procedure?
Only face to face visits can be used. The only radiology
that is considered to fulfill that is Interventional Radiology.
Otherwise, the report itself cannot be submitted for
validation. A doc must mention the disease in their
progress note.
Providers also indicate the patient has a "history of" a
condition, when we know it actually is a current condition,
based upon the fact that there are rx treating the condition
and there may be labs or other tests following it? Can this
PMH be used to support an HCC? What if it is
documented in PMH, and you can see ROS and exam
pertinent to the condition? There is also sometimes a note
to continue rx or treatment for but only in PMH?
Medicare looks at the "totality" of the note. If there is
discrepant information, we query our doctors as "history
of" and "active" cancer are a coder's headache due to the
mixed documentation in the chart. If the totality of the note
clearly supports that the patient really does have cancer, the
one mis-statement will be discounted. If at all possible,
choose a different note for validation. Otherwise, it is the
subjective opinion of the auditor and we all know how that
can go.
Do you have written documentation to support only one of
the MEAT items are enough to support the HCC? I have
had healthplan audits that remove the HCC as there is no
treatment plan.
Medicare has not released any written guidance on this
since 2008 in the Risk Adjusment: Regional Technical
Assistance manual. There are those that argue that any one
of the MEAT criteria are enough. If a doc clearly mentions
that they have a cancer, even as a passing comment when
treating their depression, that is enought to validate that the
patient really has that active condition. When they say
"History of" - sometimes that means active, (hisotry of DM,
they are not cured....) - sometimes it really does mean that
in the past they had a condition.
Do you have the hcc list for 2014?
The model will be similar to 2013. They have not release
the ICD-10 mapping yet.
When a patient is diagnosed with cancer, treatment is
The coding clinic specifically states that they either need to
recommended but the patient declines, should this be coded have evidence of "active" cancer or evidence that it is no
as active cancer or history of cancer?
longer present or "erradicated". "A personal history of
malignant neoplasm identifies a malignancy that has been
previously treated or removed but for which there is no
current treatment for the condition and no evidence of the
disease" The key is "no evidence of the disease. If they
refuse treatment, as long as there is documentation stating
they still have the cancer but decline treatment, then you
can submit the diagnosis. You can't submit it if the cancer
is gone and no more treatment is being rendered. Since
there was no treatment, it still exists.
Can you provide the specific source from whence the
MEAT concept originated?
This is what our organization came up with as well as a
completely different organization - a large Health Care
entity in San Diego. These criteria were developed after
discussions by our attorneys with CMS in an attempt to
clarify the exact criteria. CMS has not released much and
are vague when you try to get specific instructions. It is
more of a wide understanding in the industry rather than
source documentation directly from the government.
V22 is the HCC list for 2013 dates of service. CMS calls it
the 2014 HCC list but they always refer to payment year.
So on the CMS website you will find the 2014 HCC list
which is the same thing as the V22. It is the HCC list for
2013 dates of service.
We do not refer to it as the V22 model in our organization
and we are all vicitm of organizational bias and jargon.
Thanks for clarifying. The model is expanding in from 70
to nearly 80 in 2014. Once again - they have not released
the ICD-10 specific mapprings for the codes. They have
just added some categories and renumbered others.
Do you allow coding a chronic condition like DM, CHF,
COPD off of a Problem list and medicaton list alone?
There are specific guidelines if you use the problem list
alone. There must be an entry in the Problem List with a
date and comment from the doc on how they treated the
condition in the problem list. That very seldom occurs so
Problem Lists in general are not a source to validate the
patient has a condition. It really needs to be refered to in
the body of the qualified clinicians progress note or
assessment.
Are we going to have to send reminders to patients to come Having them pay less would create the perverse incentive
in for their appointnments so you pay less?
of a patient waiting until they get their notice to come in so
they can then get a discounted visit. It is not good
medicine from a quality standpoint for someone to be on
medication for a disease and not see them for an entire year.
We need to make sure what we are doing is working via
exam or blood tests.
How can find out the criteria you used to run the epic
reports
I would be happy to discuss what we do in EPIC and what
types of reports we have. Please email me with any
specific questions and I will answer or set up a time we can
discuss. james.m.taylor@kp.org (please send on company
email or my spam filter takes out yahoo and gmail
messages and I never see them)