HCC (Hierarchical Coding Category) Coding Support | February 2023 | News Flash

February 22, 2023


HCC (Hierarchical Coding Category) Coding Support


McLaren is working with Stanson Health, a Premier Company (Cerner OneMcLaren sites) and Persivia (Non-Cerner sites) to help capture HCC codes, by prompting providers within their workflow as to conditions that have not yet been coded. As a reminder, CMS uses HCC codes to classify the ‘acuity’ of individual patients to estimate future years reimbursement.


Why should I care about HCC coding?

  • It is a loss of revenue to your practice through reduced gainsharing on value-based contracts if you are not coding to the highest severity of illness.
  • Because you think your patients are sicker than other providers’ patients. Risk Adjustment Factor (RAF) scores can show that to be true (or not).


What is HCC?

  • HCC coding is a risk adjustment methodology used by CMS to rate the complexity of and projected cost of caring for individual patients in Medicare, Medicare Advantage and Medicaid programs.
  • In HCC coding, a Risk Adjustment Factor (RAF), often referred to as the “HCC Score,” is assigned to each patient, which is a sum of factors based on:
    • Age and gender
    • Other demographic information, such as Medicaid and/or disability status
    • Diagnoses, particularly chronic medical diagnoses (but many diagnoses do not contribute to the RAF)
  • To give an idea of the scale, the methodology was designed to give the average Medicare beneficiary an HCC score of 1.0.
  • RAFs are calculated based on diagnoses submitted with claims.
  • RAFs are reset to zero at the beginning of each calendar year.
  • Coding of chronic conditions needs to be re-captured at the start of each calendar year


What do I need to do?

  • Code the patient’s problems and conditions to the highest degree of specification.
  • Code all chronic conditions at least annually (which requires seeing them annually).
  • When you enter a problem as a visit diagnosis, ensure your documentation has “MEAT”: that your documentation shows that you are monitoring, evaluating, assessing, and treating the problem.
  • Look for the most common opportunities to improve the RAF score by accurately and appropriately coding such as diabetes, morbid obesity, CKD


How does this impact my workflow?

  • Available in EHR workflow. Actionable HCC alerts are made available in the EHR at the point of care and are designed to notify you if a new or different HCC code should be considered to optimize diagnosis coding.
  • Inferred diagnosis. These HCC alerts are not solely reliant on prior coding history, nor do they focus primarily on the recapture of codes that require documentation on a yearly basis. This helps enable identification of new codes that have not been previously documented, which may result in a year-over-year increase in risk adjustment factor (RAF) scores.
  • Actionable alerts. These alerts are designed to be actionable and built to limit the provider’s administrative burden. They will help you to update the HCC code in the workflow, avoiding the need to remember to update the code later or navigate to a different part of the EHR to complete the task.
  • Provider efficiencies. The alerts are designed to offer provider efficiencies across the care continuum, with the goal to help improve patient care, risk score outcomes, billing compliance and the potential to optimize Medicare reimbursement.
  • Example. If your patient has “Type 2 DM without complications”, E11.9 (RAF score 0.105), on their problem list, but the last HgbA1C value was above 8%, it will prompt you to add “Type 2 DM with hyperglycemia”, E.11.69 (RAF score 0.302) to the visit diagnosis and problem list, which has a higher HCC score than the more non-specific code. The risk score is now 3X the weight when using a code that is the most specific and indicates a higher severity of illness.


In practices on Cerner One McLaren, these alerts began firing silently in the background on 2/16/2023. This activity will continue for several weeks, after which MPP will analyze the data and make the coding alerts visible to providers in the live environment.


In Non-Cerner sites, MPP will be rolling out Persivia CareTrak to those EMRs already integrated.


For more information, please contact Dr. Michael Ziccardi, CMO, at michael.ziccardi@mclaren.org or  (248) 484-4923.