hcc risk adjustment

There are two different models for Hierarchical Condition Category (HCC) risk adjustments. The U.S. Department of Health and Human Services (HHS) oversees the HHS-HCC model, which covers commercial payers of all ages and determines risk payments for the current year. The Centers for Medicare and Medicaid Services (CMS) uses the CMS-HCC model for the Medicare Advantage program and those who qualify for Medicare or patients 65 and older, calculating risk payments for the next year. Both HCC models use a risk adjustment factor (RAF) score to calculate expected future health costs for each patient.

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hcc coding

Every healthcare organization that has Medicare patients who receive coverage and benefits through the Medicare Advantage program uses HCC coding. CMS established the HCC coding risk-adjustment model in 2004 to better predict healthcare costs for every patient and increase the accuracy in risk adjustment data for reimbursement claims (AAFP, 2020). But, what is HCC coding? Hierarchical condition category (HCC) coding utilizes the ICD-10 code set to identify risks for each patient and assign risk values, or RAF scores, in value-based care models. If your coding team needs HCC coding help, here are 4 HCC coding best practices you can implement right now to see a positive impact immediately.

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ICD 10 PCS 2020

This article will highlight the ICD 10 PCS Updates 2020 and Guideline changes, and briefly present some of the code additions for the Medical and Surgical Section. For a description of all of the code changes, including updates to the Medical and Surgical Related Section, Ancillary and New Technology, as well as the rationale and clinical information as detailed in the Coordination and Maintenance Committee Meeting materials, please sign up for the ICD 10 PCS Updates 2020 for FY 2021 medical coding webinar available soon at YES HIM Consulting. The PCS coding updates course will be available on the YES Education site.

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CMS guidelines for telehealth

The Centers for Medicare & Medicaid Services (CMS) has decided to update the CMS billing and coding guidelines for telehealth or in-home provider services due to the urgency of the current 2019-Novel Coronavirus (COVID-19) pandemic (CMS, 2020). CMS has broadened the scope for reimbursement for virtual check-ins and other digital communications with patients to safely and effectively respond to this Public Health Emergency (PHE). In the interim, telehealth services will not be limited by program restrictions put in place by Medicare (Federal Register, 2020). Evaluation and management (E/M) service codes cover these remote and communication technology-based services performed by a physician or non-physician practitioner (NPP).

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medicare telehealth services

The Centers for Medicare & Medicaid Services (CMS) has decided Medicare will expand its payment protocol for professional Medicare telehealth services provided to beneficiaries in all areas of the country, in all settings. “Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health” (CMS, 2020). Due to the current Public Health Emergency (PHE) declared for 2019 Novel Coronavirus (COVID-19), this expansion was considered a necessary step to assist in healthcare reimbursement and only designed to last as long as this emergency

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Telehealth and Covid-19

CMS clarified on April 10, 2020, that the submission of ICD-10-CM diagnoses codes for Risk Adjustment are permitted from coding telehealth services as long as it meets the set criteria (i.e. inpatient, outpatient, or professional service and from a face-to-face encounter) (CMS, 2020). CMS is stating that telehealth services can meet the face-to-face requirement “when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication” (2020). From a medical coding and billing standpoint, the change in the telehealth services criteria for risk adjustment is causing updates to how these services are billed.

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Quality Payment Program

In the 2020 Medicare Physician Fee Schedule Final Rule released by the Centers for Medicare and Medicaid Services late last year, several changes were made to the value-based Quality Payment Program (QPP) (Journal of AHIMA, 2020) to simplify the rules for providers. According to the Journal of AHIMA (2020), these updates will “impact more than 1 million clinicians eligible for one or both of the QPP’s two performance tracks, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). CMS estimates that 880,000 clinicians will be MIPS-eligible in 2020, and between 210,000 and 270,000 clinicians will achieve Qualifying APM Participant (QP) status in 2020.”

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On March 11, the World Health Organization (WHO) issued a declaration of the COVID-19 as a global pandemic. Two days later, the AMA announced the development of a specific code for laboratory testing for the coronavirus, code 87635 (AMA, 2020). The Centers for Medicare and Medicaid Services (CMS) released two new HCPCS codes for coronavirus testing for Medicare claims. The reporting for COVID-19 testing is dependent on the payer, either an HCPCS or CPT code should be used; there should not be more than one COVID-19 testing code on a given claim.

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ICD-10-CM code U07.1 COVID-19 will be in effect as of April 1 in the US, which was pushed up from the normal effective date of October 1 for new codes. The reasoning for this unprecedented change is for the urgent need of immediate data collection. CMS has released a new update on 3/23/2020: “The ICD-10 MCE Version 37.1 R1 uses edits for the ICD-10 codes reported to validate correct coding on claims for discharges on or after April 1, 2020″ (2020). The ICD-10 MS-DRG Grouper software package to accommodate this new code, Version 37.1 R1, is effective for discharges on or after April 1, 2020.

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Medicare Payment Systems

The Centers for Medicare & Medicaid Services (CMS) is implementing 8 major changes this year to the Medicare payment systems, according to Becker’s ASC Review (2019). A majority of these changes come from the organization’s 2020 Medicare Hospital Outpatient Prospective Payment System and ASC Payment System Final Rule (CMS, 2019). Other changes were due to the finalization of the CY 2020 Medicare Physician Fee Schedule Final Rule (CMS, 2019).

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