Sunday, May 12, 2013

10 Guiding Principles of HCC Coding

Compliant Coding and Documentation begins with Education.... 

The following 10 principles guided the creation of the CMS-HCC diagnostic classification system:

 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.”

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