Diagnosis codes are increasingly used by accountable care organizations and others using alternative payment models to assess the health status of patient panels. By mapping ICD-10 codes to Hierarchical Condition Categories (HCCs), payers can factor severity of illness into value-based payment calculations, including shared savings allocations. Skeptical physicians may expect “HCC coding” to require more time clicking boxes with additional risk for payment cuts. However, we have found that by using a simple workflow intervention and tool, physicians can ensure that their diagnosis coding is informed by HCCs and optimized for payers' risk adjustment calculations. Here's how it works.
First, identify which of a patient's chronic conditions have diagnosis codes weighted for risk adjustment. Qualifying diagnoses are typically specific, chronic, and predictive of significantly higher health costs. Electronic health record (EHR) systems can help with this process, but physician familiarity with these codes is still essential. For this reason, we created a three-page reference tool listing common diagnoses and the HCC weight for each one. We post it near our computers, where we can glance at it as we review our patient's problem list before the encounter. Our EHR time-stamps when a given problem was last updated. This information and the tool help us choose which chronic conditions to address during the visit and guide our coding for the encounter. (See “ICD-10 — HCC coding reference for family medicine.”)
Understanding Hierarchical Condition Categories (HCCs) and annually reporting ICD-10 codes that correspond to them is vitally important under new payment models that shift financial risk to physicians.
Using a quick reference tool that lists ICD-10 codes that have HCC weights can help busy practices make sure their coding accurately reflects their patients' complexity.
For example, consider Mr. White, a 62-year-old male who was seen in our clinic for a new patient visit. He had been seen in our health system in the past, so his medical history was well-documented in our EHR. A quick review of his problem list showed 19 chronic conditions. Comparing this list with our reference tool, only one — chronic hepatitis C status (ICD-10 code B18.2) — has an HCC weight. This was one of several conditions we addressed during his appointment, and we made sure to code for it and document the current status of the condition and plans for addressing it. Many common chronic conditions, such as Mr. White's hypothyroidism and essential hypertension, do not correspond to HCCs. Mr. White's problem list also includes “depression with anxiety” (F41.8). We scheduled a follow-up appointment for Mr. White in one month to discuss his mood concerns and requested records from his previous therapist. If we determine that Diagnostic and Statistical Manual of Mental Disorders criteria are met, “major depressive disorder, recurrent” (F33.9) or “major depressive disorder, in partial remission” (F32.4) might be a more appropriate diagnosis. Both have HCC weight.
Clinics in value-based payment settings must document and report as many qualifying diagnoses as possible for each patient annually. This should be a natural extension of taking a thorough medical history and addressing chronic conditions and health concerns in a consistent manner. We advise using your EHR's problem list feature to track relevant diagnoses, comparing them to our coding tool, and paying hawk-like attention to when they were last addressed.
|Type 2 diabetes (T2D)|
|T2D without complications||E11.9||19||0.104||Always has HCC weight.|
Document as specifically as possible.
|T2D with hyperglycemia||E11.65||18||0.318|
|T2D with hypoglycemia, no coma||E11.649||18||0.318|
|T2D with mild retinopathy||E11.329||18||0.318|
|T2D with diabetic chronic kidney disease (CKD)||E11.22||18||0.318|
|T2D with polyneuropathy||E11.42||18||0.3168|
|Long term (current) insulin use||Z79.4||19||0.104|
|HTN with congestive heart failure (CHF)||I11.0||85||0.323||Isolated essential HTN has no HCC weight.|
Relationship must be explicitly documented.
|HTN + CKD stage 5/end stage renal disease (ESRD)||I12.0||136||0.237|
|HTN + CHF + CKD stage 1–4||I13.0||85||0.323|
|HTN + CHF + CKD stage 5/ESRD||I13.2||85||0.323|
|HTN + heart disease (no CHF) + CKD 5/ESRD||I13.11||136||0.237|
|Chronic kidney disease (CKD)|
|CKD stage 4, glomerular filtration rate (GFR) 15–29||N18.4||137||0.237||No HCC weight unless stage 4 or worse, or associated with HIV.|
|CKD stage 5, GFR <15||N18.5||136||0.237|
|HIV/AIDS||B20||1||0.312||Active infections — serious, systemic, opportunistic, or bone/joint/muscle.|
|Breast cancer||C50.9||12||0.146||Active cancers — new, under treatment, or treatment declines — with documentation of any metastases.|
|Lung, gastrointestinal, or pancreatic cancers||Varies||9||0.970|
|Metastasis to lymph nodes||C77.X||8||2.625|
|Immune thrombocytopenic purpura||D69.3||48||0.221|
|Morbid obesity||E66.01||22||0.273||No HCC weight unless BMI is 40 or greater or there are comorbidities.|
|Code BMI if known||Z68.41–45||22||0.273|
|Protein-calorie malnutrition||E46||21||0.545||Malnutrition requires documentation of objective data (e.g., albumin less than 3.4) or subjective data (wasted appearance).|
|Chronic lung disease|
|Smoker's cough||J41.0||111||0.328||Document specifically if possible (smoking history, chest computed tomography results, pulmonary function tests, etc.).|
*Also code Z99.81, dependent on supplemental oxygen.
|Chronic obstructive pulmonary disease (COPD), other||J44.X||111||0.328|
|Chronic respiratory failure||J96.10*||84||0.302|
|Inflammatory bowel disease|
|Chronic hepatitis C||B18.2||29||0.165|
|Chronic hepatitis, unspecified||K73.9||29||0.165|
|Esophageal varices, no bleed||I85.00||27||0.962|
|Sicca syndrome (Sjoren)||M35.00||40||0.423|
|Schizophrenia||F20.9||57||0.608||“Run-of-the-mill” depression/anxiety has no HCC weight.|
Must document Diagnostic and Statistical Manual of Mental Disorders criteria.
|Major depression, recurrent||F33.9||58||0.395|
|Alcoholism, in remission||F10.21||55||0.383|
|Drug dependence, in remission||F1X.21||55||0.383|
|Parkinson's disease||G20||78||0.585||Remember to list these chronic diseases annually, even if primary management is by a consultant.|
|Coronary artery disease with angina||I25.119||88||0.140|
|Acute myocardial infarction||I21.3||86||0.233|
|Abdominal aortic aneurysm||I71.4||108||0.298|
|Deep venous thrombosis (DVT)|
|Peripheral vascular disease||I73.9||108||0.298|
|Diabetic peripheral vascular disease||E11.51||18||0.318|
|Venous stasis ulcers with varicose veins||I83.0||107||0.400|
|Chronic venous stasis ulcer||I87.31||107||0.400|
|Wet macular degeneration||H35.32||124||0.499|
|Proliferative diabetic retinopathy||E11.359||18||0.318|
|Concussion w/o loss of consciousness, sequelae||S06.0X0S||167||0.191||Any code reflecting major or severe head trauma has HCC weight.|
|Head injury with subdural hemorrhage||S06.6X6A||166||0.584|
|Specify site||Z89.4-6||189||0.588||Lower limb only.|
|Major organ transplant|
|Heart transplant status||Z94.1||186||1.000||Can be any duration from surgery.|
|Lung transplant status||Z94.2||186||1.000|
|Liver transplant status||Z94.4||186||1.000|
|Excluded chronic conditions|
|Essential hypertension, hyperthyroidism or hypothyroidism, iron deficiency anemia, gastroesophageal reflux, osteoarthritis, and tobacco use.|