The Centers for Medicare & Medicaid Services (CMS) announced significant changes to the Hierarchical Condition Category (HCC) risk-adjustment model earlier this year. In order to help our customers and anyone who needs to manage the shift from HCC version 24 (V24) to version 28 (V28), IMO has published numerous resources including blogs, a guide, and a webinar which you can watch here, on demand. We’re adding to this trove of helpful information with this article, exploring how IMO’s problem list solutions can become an integral part of any successful HCC strategy, improving the specificity of documentation, providing greater visibility to HCCs, and driving higher risk adjustment factor (RAF) scores.
The first step toward HCC success, however, is making providers more aware of HCCs. This starts with aligning providers to the importance of managing HCCs, both in terms of controlling chronic conditions to mitigate future cost, as well as optimizing Medicare Advantage reimbursement. But to help achieve this aim, it is important that providers are able to quickly identify HCCs when preparing for an encounter and when documenting new problems and diagnoses.
Apply HCC flags to problem and diagnosis terms
IMO Core can help improve awareness within an encounter in two ways. First, when searching for a new problem or diagnosis, IMO’s terminology supports flags and indicators that call out search results that are mapped to HCCs. The actual indicator may vary depending on the electronic health record (EHR), but generally speaking, IMO supports such indicators for both v24 and v28 HCCs, as well as other risk models such as PACE and HHS-HCCs.
Secondly, IMO Core’s problem list displays support the same indicators next to problems that are mapped to HCCs. This can assist a provider in quickly identifying these conditions for follow up in the encounter. Additionally, IMO Core can automatically differentiate between HCCs that have already been addressed within the calendar year, versus those that have not, further assisting the provider in prioritizing HCCs for review.
In some EHR systems, IMO Core is able to go a step further, considering previous encounters to identify HCCs that may have been addressed in a previous encounter, which may not be easily accessible to the provider. A consolidated view pulls all of a patient’s persistent HCCs into a single tab that applies CMS exclusion rules to prioritize just those conditions that may impact the patient’s RAF score.
Ensure providers have visibility to existing HCCs
IMO recommends embracing the problem list as a way for providers to ensure visibility into HCCs. The purpose of the medical problem list is to give providers a summary of ongoing patient problems that need to be managed over time. Coincidentally, this is the goal of Medicare Advantage and the HCC model, but with a particular focus on a subset of (predominantly) chronic conditions.
To this end, IMO has recently launched the latest offering in our suite of problem list solutions, IMO Discovery for Problems, which can identify HCCs from previous encounters or unstructured clinical notes and provide in-workflow “nudges” to consider inclusion on the problem list. With visibility to all persistent HCCs on the problem list, providers will be equipped with a full accounting of the conditions that need to be addressed, and most importantly a fuller understanding of the patient’s clinical story.
Ensure specific and complete codingAlso key to HCC success is coding specifically and completely. Ensuring providers are capturing conditions with the appropriate level of clinical detail can result in thousands of reimbursement dollars for a single patient. (For a straightforward example, see the chart below).
|Diabetes w/ CKD w/ long-term current use of insulin (E11.22)
|CKD 3b (N18.32)
|No CKD coded
|Long term current use of insulin (Z79.4)
|Insulin use not coded
|Payment Bonus = $3,339
|Payment Bonus = $945
IMO Core’s search tooling is designed to ensure that diagnoses are coded with the appropriate level of clinical detail. IMO’s ICD-10 modifier workflow prompts the provider with targeted questions to capture the specificity necessary to avoid denied claims and optimize risk scores. Further, IMO’s clinical terminology supports secondary code mapping, automatically coding additional ICD-10-CM codes that may contribute to the patient’s RAF.
Simplify documentation with greater access to relevant data
In addition to coding an HCC on a given encounter, providers also need to provide documentation to support the diagnosis. Many organizations use the M.E.A.T. criteria – Monitoring, Evaluation, Assessment, and Treatment – for this documentation. IMO Core can make this easier by displaying relevant medications and lab results within the context of a selected problem. With a click, a provider can access the necessary clinical information without having to traverse siloed data within the patient’s chart.