HCC Blog by Caridad

 CMS RxHCC can be found on this document which is the same document as the mapping. If you are interested, the corresponding weights are found here: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Final-2021-Benefit-Year-Final-HHS-Risk-Adjustment-Model-Coefficients.pdf Page 12

 CMS.gov Internet Only Manuals Medicare Managed Care Manual Chapter 7 contains information on Risk Adjustment, 75 page document In 2021, the current manual is dated:   (Rev. 118, 09-19-14) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326

The HCC model and corresponding diagnosis code can be found on this pdf from CMS.  (Includes ICD-10 codes valid in FY2020 or FY2021, effective 1/1/21.) Medicare > Medicare Advantage Rates & Statistics > Risk Adjustment > 2022 Model Software ICD-10 Mappings

Disease coefficient values for calendar year 2021 can be found on these pages in the link below: Table VI-1. Alternative Payment Condition Count (APCC)      page 74 Disease Coefficients                                                           page 75 Disease Interactions                                                            page 79 Payment HCC Counts                                                       page 80 https://www.cms.gov/files/document/2021-announceme...

 Acceptable Physician Specialty Types for 2021 https://www.hhs.gov/guidance/document/2021-acceptable-physician-specialty-types

From the Department of Justice, Office of Public Affairs News dated Friday, July 30, 2021 The article states allegations against Kaiser on submission of HCC diagnoses: "Medicare requires that, for outpatient medical encounters, MA Plans submit diagnoses to CMS only for conditions that required or affected patient care, treatment or management during an in-person encounter in the service year. In order to increase its Medicare reimbursements, Kaiser allegedly pressured its physicians to create addenda to medical records after the patient encounter, often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements.      The lawsuits were filed under the qui tam, or whistleblower, provisions of the False Claims Act" It will be interesting to follow this story and see how it turns out. https://www.justice.gov/opa/ pr/governme...

Thanks to Sheri Poe Bernard’s post on LinkedIn, here is a link to downloading all the ICD-10-CM codes and guidelines from CMS.  These are PDFs that can be downloaded to your desktop and searched using ‘Control F’. https://www.cdc.gov/nchs/icd/icd10cm_browsertool.htm   ICD-10-CM Browser Tool:              https://icd10cmtool.cdc.gov/ Once on this page, from the ‘Fiscal Year’ drop down menu, chose the year you want to view and there is a place to ‘Search for all term(s).   Over on the right side of the screen, there is a blue link where you can see ‘Guidelines’ and enter the exact code to search for.   Information includes: FY 2021 – includes Jan 2021 Addenda FY 2020 – includes Apr 2020 addenda FY 2019 – Oct 1 2018 FY 2018 – Oct 1 2017   Help guide:   https://icd10cmtool.cdc.gov/static/ICD-10-CM-Web-Help.pdf     Fun Facts: The National Center for Health Statistics ...

This post is not risk adjustment related but a reference new codes for COVID-19:  The topic is  "Special Announcements for the ICD-10-CM Coronavirus (COVID-19) & Vaping Coding" *Various codes from COVID-19 *New ICD-10-CM Code 2019 Novel Coronavirus (COVID-19) *New ICD-10-CMD code for vaping *Vaping Coding Guidance 2019 ICD - ICD-10-CM - International Classification of Diseases, Tenth Revision, Clinical Modification (cdc.gov) [https://www.cdc.gov/nchs/icd/icd10cm.htm CDC > NCHS > Classification of Diseases, Functioning and Disability As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS) is implementing additional codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for reporting to include:  • Encounter for screening for COVID-19 (Z11.52)  • Contact with and (suspected) exposure to COVID-19 (Z20.822)...

 From the MLN Web-based Training Course this is a course on 'Diagnosis Coding: Using the ICD-10-CM' It is a free course from CMS, HHS & Me dic are Learning Network. "This 1-hour course offers information on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) as well as the ICD-10-CM classification system and coding examples." There are four lessons on this topic. Happy learning! Diagnosis Coding: Using the ICD-10-CM (cms.gov) Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of...

I am sharing an article that spells out great information on coding for hypertension. The HCCs available in this category include:   Hypertensive heart disease with category I11,  Hypertensive chronic kidney disease with category I12 Hypertensive heart and chronic kidney disease with category I13. Take the Guesswork Out of Hypertension Coding  https://www.aapc.com/blog/52789-take-the-guesswork-out-of-hypertension-coding/ Happy Coding! Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.

T ype 2 diabetes mellitus with other diabetic kidney complications (ICD-10 code E11.29 ).  The associated terms can include microalbumuria or renal impairment.  I am sharing a bit of information on the physiology around this condition. This video in YouTube has a great explanation of the labs that give a general idea about the condition, at minute 3:03 .  The presenter is Real World NP and the name of the video is "Microalbuminuria Case Study: Lab Interpretation for Nurse Practioners". https://www.youtube.com/watch?v=dSpx8eLA96U Documenting for Microalbuminuria: if patient tests positive for moderately increased albuminuria (microalbuminuria) consistently over a period of at least 3 months, the provider should document the duration in the chart note and describe the condition as “persistent”, as appropriate.  Coders do not determine codes based on labs.   Lab values: Normal Micro-moderate increase albuminuria Macro-severely ...

Sharing this great podcast that I found on Linkedin.  It was presented by Allen Frady and a guest whose name I missed.  It is entitled: "Coder vs CDI Episode 1. Is the Coder locked into only a "literal translation"? Coder autonomy, clinical validation and coding guidelines" click below, and is is available on Spotify under 'Mr. CDI rambles about hospital' https://infotainmentforcdiandcoders.buzzsprout.com/1588225/7287109-coder-vs-cdi-episode-1-coder-autonomy-clinical-validation-and-coding-guidelines