Compliant Coding and Documentation begins with Education....
•Principle 1—Diagnostic categories should be clinically meaningful.
•Principle
2—Diagnostic categories should predict medical expenditures.
•Principle
3—Diagnostic categories that will affect payments should have adequate sample
sizes to permit accurate and stable estimates of expenditures.
•Principle
4—In creating an individual’s clinical profile, hierarchies should be used to
characterize the person’s illness level within each disease process, while the
effects of unrelated disease processes accumulate. Because each new medical problem adds to an
individual’s total disease burden, unrelated disease processes should increase
predicted costs of care. However, the
most severe manifestation of a given disease process principally defines its
impact on costs. Therefore, related
conditions should be treated hierarchically, with more severe manifestations of
a condition dominating (and zeroing out the effect of) less serious ones.
•Principle
5—The diagnostic classification should encourage specific coding.
•Principle
6—The
diagnostic classification should not reward coding proliferation. The classification should not measure greater
disease burden simply because more ICD-9-CM codes are present.
•Principle
7—Providers should not be penalized for recording additional diagnoses
(monotonicity). This principle has two
consequences for modeling: (1) no condition category (CC) should carry a
negative payment weight, and (2) a condition that is higher ranked in a disease
hierarchy (causing lower-rank diagnoses to be ignored) should have at least as
large a payment weight as lower-ranked conditions in the same hierarchy.
•Principle
8—The classification system should be internally consistent (transitive).
•Principle
9—The diagnostic classification should assign all ICD-9-CM codes (exhaustive
classification).
•Principle
10—Discretionary diagnostic categories should be excluded from payment models.
Characteristics
of CMS-HCC Model
•What is a Hierarchical Condition Category?
▫Category of medical conditions that map to a corresponding group of ICD-9 diagnosis codes
•2,913 ICD-9 Codes Map to 1 of 70 HCC’s
*Per the ICD-9-CM Official Guidelines
for Coding and Reporting:
“Code all documented conditions that
coexist at the time of the encounter/visit, and require or affect patient care
treatment or management.”
If you would like to learn more information about HCC Coding please visit our website: www.ermconsultinginc.com or www.cms.gov
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