Managing HCCs for the right reimbursement

Sometimes close enough is good enough, but for those capturing and documenting high-risk patient diagnoses in the EHR, added specificity is key.
HCC-Reimbursement

In the alphabet soup of healthcare IT, some acronyms matter more than others. When it comes to reimbursements, the importance of HCCs – Hierarchical Condition Categories – cannot be overstated.

HCC codes are critical to reimbursement

HCC codes lie at the heart of a payment methodology used by the Centers for Medicare and Medicaid Services (CMS) to determine capitated payments for Medicare Advantage (MA) and other Medicare programs. These codes allow payments to be risk-adjusted based on patient complexity, leading to increased payments for high-risk patients. CMS requires that all diagnosis codes be reported to the highest level of specificity. 

Specificity matters to your bottom line

For providers, the implications are clear – the ability to document with greater specificity and precision can dramatically impact payments. The chart below illustrates how precise clinical documentation can boost payments.

DiagnosisICD-10-CMHCCPremium Bonus
Diabetes with no complicationsE11.919$894.40
Diabetes with diabetic neuropathic arthropathyE11.61018$1094.40
Diabetes with hyperosmolar comaE11.0117$1094.40
Diabetes with ESRDE11.22, N18.618, 136$1273.60
Diabetes with ESRD on chronic dialysisE11.22, N18.6, Z99.218, 136, 134$1475.20

Consider an HCC strategy

In our white paper, Get the right reimbursement for high risk patients A proven strategy for managing Hierarchical Condition Categories (HCCs) in your EHR, we not only outline a proven strategy to maximize your HCC capture but also discuss:

  • What HCCs are
  • How much money a lack of specificity is costing you
  • A solution to effectively capture HCCs in your EHR and maximize reimbursement

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