HCC Coding 101: How to Avoid Scrutiny As Risk Adjustment Schemes Come to Light

HCC Coding 101: How to Avoid Scrutiny As Risk Adjustment Schemes Come to Light

Several recent lawsuits have brought to light a list of risk adjustment schemes to increase reimbursements in violation of the False Claims Act. The news forces healthcare providers to reflect on their own practices in an effort to make sure they are compliant and meet the HCC documentation requirements.

The US government started investigating Kaiser Permanente after six complaints were received about inaccurate diagnosis codes for Medicare Advantage patients (US Department of Justice, 2021). Sutter Health and affiliates will pay $90 million to settle a False Claims Act suit after the group submitted false health status information for its Medicare Advantage patients (US Department of Justice, 2021).

As the Office of Inspector General (OIG) continues to scrutinize Medicare Advantage claims for improper coding, healthcare organizations should take the opportunity to find and fix any coding compliance risks.

HCC Coding 101: Best Practices

A compliant HCC coding process follows the strict guidelines that dictate which code to assign per health condition and reports only the disease conditions that the provider documents and the patient displays. It is also wise to utilize specificity in your HCC documentation and coding process to support every diagnosis. This can be achieved with the M.E.A.T. Criteria.

What does MEAT stand for in HCC coding? The M.E.A.T. Criteria can be explained as such:

The CMS-HCC model focuses on long-term chronic conditions such as diabetes, autoimmune disorders, end-stage liver disease, end-stage renal disease, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) that impact the probability of future healthcare costs. HCC categories report all conditions that affect the patient’s health status concurrently across the continuum of care.

To support an HCC, the medical record must support the presence of the disease/condition and include the clinical provider’s assessment and/or plan for managing the disease/condition. They cannot just be listed within the “problem list.” Coding professionals need to review the entire medical record documentation to assign appropriate ICD-10-CM diagnosis codes.

Specificity is also key to accurate coding and HCC assignments. For example, Major depressive disorder, unspecified, is assigned no HCC; therefore, no additional risk factor. However, documentation meeting the M.E.A.T criteria of Major depressive disorder, single episode, mild, would result in a more specific ICD-10-CM diagnostic code as well as HCC 59, which would be an additional relative risk factor of 0.355 (and a potential predicted cost of $3,325). Additional HCC coding 101 best practices include ongoing education on codes and guidelines, especially as updates are introduced. Knowledge of the most current HCC coding guidelines will reduce the risk of noncompliance.

Furthermore, an HCC Coding Specialist can assist in proper HCC assignment and risk score calculations. HCCs can be a complex subject, so it is always best to rely on an expert if your team is unsure of how to assign these codes.

Are you worried that your risk adjustment process is not compliant, or are you looking to improve your HCC coding practices? Get in touch with one of our HCC Coding Specialists to develop a custom plan for your organization.

Review these additional HCC coding resources:

• Why is HCC Coding Important? YES Case Study Highlights HCCs & Healthcare Technology
• How an HCC Coding Audits Partner Can Help Your Facility
• HCC Consulting Case Study: Bridging the Gap Between Medical Software Companies & Coding
• Everything You Need to Know About the HCC Risk Adjustment Models
• Implement These Best Practices to Improve HCC Coding
• HCC Chronic Conditions and M.E.A.T. Criteria
• The Importance of Specificity in Documentation and Coding HCCs