Medicare HCC Coding

These are CMS Hierarchical Condition Categories. Medicare has classified about 3,000 of the 14,000 ICD-9 diagnosis codes into HCCs or categories designating chronic conditions that end up costing them more money over the long run, such as diabetes, kidney failure, old MI, etc. When patients are assigned these ICD-9 codes, Medicare sees those beneficiaries as being more severely ill than the "average" Medicare beneficiary. For the Medicare Advantage members, this could result in higher reimbursement. Some of the conditions included in the model are status conditions, like s/p BKA or artificial openings (i.e. colostomy, tracheostomy, etc.). Certain fractures and conditions like respiratory failure are part of the model, but may or may not be chronic in nature.

In this program you are funded by diagnosis codes, not CPT codes. The sicker the patient (the more diagnoses) the more funding you receive. Never paid on CPT code level.

HCC codes are given a severity ranking. More specific codes have a higher ranking than unspecified codes. You code as you normally would but just make sure that you are coding with ICD-9 codes as specific as possible and using all the codes that apply to that visit per the documentation. If you use codes with a higher HCC ranking, you get more "credit". For example, if a patient is diabetic and they have other problems associated or caused by the diabetes, use the most specific codes 250.4x or 250.5x, etc instead of 250.0x.

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