Whatever the industry, we all want to get paid for the work we do. For healthcare providers in the US — particularly those treating Medicare Advantage (MA) patients — the key to securing the right reimbursement lies in both understanding and correctly billing for Hierarchical Condition Categories (HCCs).
Accurate HCC coding helps to create a more complete picture of a patient population, improves the value of medical problem lists, and enables better management of chronic conditions. But improving the process of HCC capture and precise documentation can also dramatically impact Centers for Medicare & Medicaid Services (CMS) payments, as illustrated below.
| Diagnosis | ICD-10-CM | HCC | Premium Bonus |
|---|---|---|---|
| Diabetes with no complications | E11.9 | 19 | $894.40 |
| Diabetes with diabetic neuropathic arthropathy | E11.610 | 18 | $1094.40 |
| Diabetes with hyperosmolar coma | E11.01 | 17 | $1094.40 |
| Diabetes with ESRD | E11.22, N18.6 | 18, 136 | $1273.60 |
| Diabetes with ESRD on chronic dialysis | E11.22, N18.6, Z99.2 | 18, 136, 134 | $1475.20 |
Learn how to best manage HCCs in your EHR by downloading IMO’s white paper, Get the right reimbursement for high risk patients.
Or, for a preview of the paper, read the excerpt below:
A recent case study at a 100+ physician group in northern Illinois illustrates the value gained after developing and implementing a sound HCC strategy. The group integrated IMO Core into their leading ambulatory EHR and evaluated the impact of this solution on the identification and capture of HCC diagnoses, RAF values for those diagnoses, and risk bonuses for MA patients.
Data for 43 primary care providers treating MA patients was examined before and after implementation of IMO Core, applying reasonable controls to eliminate seasonal variation in provider behavior and fluctuations in patient and provider activity. Diagnoses falling under the CMS HCC model were totaled by month and further evaluated by provider to determine monthly trends before and after implementation.
Results supported the use of IMO Core to augment the organization’s risk management strategy in several ways:
- HCC capture increased 15%
- Average HCC per patient increased 16%
- RAF values increased 24%
- Monthly risk bonuses increased by $160k, or $1.9M annually
