by Rose T. Dunn, MBA, RHIA, CPA, FACHE and Laurie M. Johnson, MS, RHIA, FAHIMA
Join us for a discussion of HCCs by two industry leaders: Rose T. Dunn, MBA, RHIA, CPA, FACHE, and Laurie M. Johnson, MS, RHIA, FAHIMA.
Rose: Hierarchical Condition Categories (HCCs) are utilized by Medicare Advantage and Affordable Care Act (Obamacare) payers for approximately 30 million individuals currently. Use of HCCs is projected to grow significantly in coming years.
Since HCCs appear at the intersection of CDI and coding, how can the coders and CDI staff work together effectively?
Laurie: Both sides need to be aware of reimbursement methodologies, including HCCs. The providers must paint a clear picture through words regarding the patient’s presentation and treatment. Any gaps are filled by the CDI queries, and then the coders can assign accurate and specific codes.
Since HCCs impact the work of both coders and clinicians, and CDI Specialists are in the middle, how would you educate each group regarding HCCs?
Rose: Well Laurie, I can tell you, it’s not always easy to educate clinicians unless we can help them see how it benefits their patients or them. The coders and CDI Specialists are a lot easier.
For the clinicians, I think it’s best to explain how HCC reimbursement is structured first and then provide them with documentation tidbits a few at a time until they get the hang of the documentation elements. It shouldn’t take long because so many of the elements are similar to those being prompted by the Clinical Documentation Specialists at the hospital. Having that reinforcement in both the inpatient and outpatient setting really works to our advantage.
Education for coders and CDI should focus on yearly changes to the codes and guidelines that determine how conditions can be captured for HCCs. Some CDI Specialists may need to supplement their strong clinical skills with basic education on how the coding system works so their documentation improvement efforts are more effective.
Laurie, we know that documentation education is really an ongoing process. What role do you see for CDI Specialists in HCCs?
Laurie: Rose, the HCC reimbursement methodology is growing in its usage. I think that it is important that coders and CDI professionals are aware of this and receive training on how some of the conditions can be further documented so that they are HCCs, when appropriate.
The clinical documentation supports professional as well as technical reimbursement and it is important to be aware how each area of healthcare is reimbursed. For example, obesity is not an HCC, but morbid obesity is. The physicians will utilize obesity and overlook the adjective “morbid.” Obesity does not impact the hospital reimbursement but could affect professional reimbursement when the condition is morbid obesity. From the other side, the professional coders could work with their physicians to reduce unspecified conditions such as congestive heart failure (CHF). This condition when unspecified is an HCC, but the technical (hospital) side requires that the type and acuity be further specified to gain a comorbid condition (CC) or major comorbid condition (MCC).
Rose: Yes, that’s right! And our coders help us get the dollars we’re entitled to with the most precise codes.
Laurie: Rose, it was nice chatting with you today about the intersection of coding and CDI in HCCs.
Rose: Yup, it’s going to take a village to win this war, Laurie. CDI and coding must be fully integrated to get it done. It was nice chatting with you again, Laurie.
Fundamentals of HCC Coding Go beyond just the diagnoses — really understand the methodology behind HCCs! Learn how from nationally recognized HCC expert, Rose T. Dunn, MBA, RHIA, CPA, FACHE.
Rose T. Dunn, MBA, RHIA, CPA, FACHE Rose Dunn is the Chief Operating Officer of First Class Solutions, Inc., a healthcare information management leader since 1988, offering professional consulting services in health information management operations and information governance issues, as well as coding support, coding quality reviews, privacy/security guidance, temporary (interim) management, revenue cycle oversight, and accreditation preparation. Rose is the author of Libman Education’s online course: Fundamentals of HCC Coding as well as “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on coding management and auditing. Ms. Dunn holds a B.S. and M.B.A. from Saint Louis University.Contact Rose at 314-209-7800 or [email protected]
Laurie M. Johnson, MS, RHIA, FAHIMA Laurie M. Johnson is a senior consultant at Revenue Cycle Solutions, LLC, a revenue cycle consulting firm specializing in revenue cycle assessments and work plan implementation; interim management with focus on process improvement; and revenue cycle education for hospitals and physician practices. Laurie is a past president of PHIMA and author of clinical coding articles for Journal of AHIMA and ICD-10 Monitor.