Hierarchical condition category (HCC) coding is a risk-adjustment model designed for patients to estimate their future health care costs.
It is a process of accommodating chronic conditions by which the amount of reimbursement to the health plans is determined. By using Risk adjustment process, clinical acuity of patients is determined concurrently prospectively, or retrospectively.
We implement the four best practices to improve our HCC coding performance as a top-performing medical organization.
We educate the providers on the Comprehensive physician documentation of a patient’s conditions to the most specificity in the EMR to facilitate robust diagnosis coding. This is the foundation of successful HCC coding.
It is important that a physician must be prepared for complex HCC patients in advance of the appointment to avoid missing to document any information. This helps us to address chronic conditions more accurately & completely and capture HCCs.
Our team of Certified risk adjustment coders (CRCs) ensure most reliable, consistent and accurate HCC coding.
Risk Adjustment auditors use several tools to access documentation.
MEAT and TAMPER are the most popular ones.
MEAT- Monitor, Evaluate, Access, and Treat. MEAT helps coders choose supporting diagnosis codes for rendered services.
TAMPER- Treatment, Monitor/ Medicate, Plan, Evaluate, and Referral. TAMPER helps coders address diagnoses in question that are presented in a list or are noted with a “history of” description. If a coder believes a diagnosis is current but it is listed under Active Problems, Ongoing Problems, Chronic Problems, Past Medical History (PMH), etc., the coder should ask, “Did the provider TAMPER with the diagnosis on the DOS?” If the answer is yes, the diagnosis is current. If the answer is no, the diagnosis is not current.
We at Synergy HCLS have benchmark for HCC coding at 98% quality and accuracy.
E/M stands for “evaluation and management”- the process by which physician-patient encounters are translated into CPT codes to facilitate billing.
There are many physicians chronically undercoding for their services due to lack of understanding of the coding rules. An excellent working knowledge of our E/M coding team is the best way to ensure optimal compliance and avoid inadvertent undercoding.
For different types of encounters there are different E/M codes such as office visits or hospital visits. There are five different levels of care within each type of encounter. For example, the 99214 code may be used to charge for an office visit with an established patient. The 99214 code is often called a “level 4” office visit because the code ends in a “4” and also because it is the fourth “level of care” for that type of visit (with the 99215 being the fifth and highest level of care).
The documentation requirements for each individual E/M code are dictated by a set of rules called the E/M guidelines. The E/M guidelines were developed by the Center for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association. Two versions have been released—the first in 1995 and the last in 1997. As per client requirement, we follow either 1995 or 1997 guidelines for coding and auditing the E/M levels.
The Key Components of E/M Documentation
The documentation for E/M services is based on three “key” components:
These key components are used to satisfy the documentation requirements for E/M coding UNLESS the physician is coding based on TIME. If time is the controlling factor, there are no specific documentation requirements for the three key components.
An inpatient is an individual who has been officially admitted to the hospital under a physician’s order. The patient will remain classified as an inpatient until one day before discharge.
However, staying in the hospital overnight does not necessarily mean that the patient is considered an inpatient.
Inpatient coding is related to the patient’s extended stay service.
Here’s why this matters:
During the stay, the patient may have a variety of tests run, will have changes in diagnosis and treatments. A lengthy stay usually results in extensive and intricate patient records which makes it important to have an experienced medical inpatient coder doing the job.
Examples of Inpatient facilities include acute and long-term care hospitals, birthing centers, skilled nursing facilities, hospices, home health services, etc.
The Inpatient Prospective Payment System (IPPS) is the reimbursement methodology used by Medicare to provide reimbursement for hospital inpatient services. It also uses ICD-10-CM diagnostic codes for billing and appropriate reimbursement but uses ICD-10-PCS as the procedural coding system.
The principal diagnosis is defined as the condition established after study that is solely responsible for admittance of the patient under the care of the hospital. The principal diagnosis is sequenced first in inpatient coding. The correct assignment of an appropriate principal diagnosis determines whether payment is made thoroughly. In short, the principal diagnosis is the key in determining the resources required by a patient.
Inpatient reimbursement is based on diagnosis-related groups (DRGs). Hence, for inpatient coding, we have medical coders with an AHIMA certification as a Certified Coding Specialist- CCS and an AAPC certification as a Certified Inpatient Coder- CIC.