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Three Factors to Look for when Coding for HCCs in the Emergency Room

by Rose T. Dunn, MBA, RHIA, CPA, FACHE

We recently received a note from a colleague:

“I have a question about emergency room facility coding regarding hcc. If the pt comes in with headache or rash or other diagnoses such as injuries and the physician states pt has diabetes or hypertension but does not state that diabetes or hypertension is affecting treatment should we code these chronic conditions?”

This is a great question and one I often see when working with my clients on the issue of correct Hierarchical Condition Category (HCC) coding.

The physician does not need to specifically state that those other conditions, diabetes and hypertension, affect the condition for which the patient is presenting to the ED. However, if it is apparent from the documentation that the physician assessed the other conditions then they should be coded. Examples of the types of documentation to look for include that the physician:

Monitored for these other conditions, e.g. ordered a lab test;
Evaluated them, e.g. noted the medication dosage for one or the other or while the patient was in the ED ensured some food was available for the diabetic; or
Treated either of them along with the presenting condition.

If the documentation is not in the record, coders always have the option to query the physician to provide additional information or clarity. However, keep in mind that querying ED physicians may not be worth the effort since ED encounters are often paid on leveling basis.

I’d welcome any readers who routinely work in an HCC environment to add your perspectives. What has been your experience?

What is HCC coding?
Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) for Medicare Advantage Health Plans. The HCC model incorporates socio-economic factors along with acute and chronic conditions to depict the patient care complexity and predict the long-term cost of care. Each Medicare Advantage patient has his or her own risk adjustment score based on the HCC coding. The HCC score may be used to affect the rate at which medical services are reimbursed for the enrollee.

Introduction to HCC Coding
Complete and accurate coding for Hierarchical Condition Categories (HCCs) presents an opportunity for improved data quality and appropriate reimbursement. Learn how from nationally recognized HCC expert, Rose T. Dunn, MBA, RHIA, CPA, FACHE.

About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

2 thoughts on “Three Factors to Look for when Coding for HCCs in the Emergency Room

  1. Jessica Zeutzius - January 30, 2019 at 9:22 pm

    I was informed by other colleagues that HCC’s were not utilized from the facility charges only the provider’s claims at this time reported on a 1500 form not a UB form. Is this true?

    • Libman Education - February 8, 2019 at 12:28 am
      Hi Jessica:
      HCCs can be derived from a number of sources, including the ED.
        •	From Hospital (regardless of hospital type) encounters
          o	Hospital inpatient, principal and secondary diagnoses
          o	Hospital outpatient diagnoses
       •	Outpatient Settings diagnoses
         o	Clinics, ED, Hospital Ambulatory Surgery, Physician Offices, etc.
      As long as the source is from a document that is documented by a CMS approved clinician:
      Physicians, Nurse Practitioners, Physician Assistants
      Clinically trained non-physicians (e.g., psychologists, podiatrists)
        •	Emergency Physicians are included in the approved clinician group.
      For more information, see:
      Hope this helps.