Risk Adjustment

CMS HCC 2019 Risk Adjustment Model: Retrospective HCC Code Capture Best Practices

Written By
Meleah Bridgeford
Director of Risk Adjustment, Payer Solutions

As your organization looks toward 2020 PY, implementing the new APCC model, and understanding how it will affect risk scores, there is still time to look at 2019 PY, conduct retrospective chart reviews, capture the new HCCs, and implement a plan for the future. Having insight into your data, using best practices and knowing how to best work with your providers will be key to ensure complete reimbursement.


V23 Model & New HCCs


First, let’s recap 2019 PY. CMS changed the list of diagnosis codes that map to HCC 54: Substance Use with Psychotic Complications, and HCC 55: Substance Use Disorder, Moderate/Severe, or Substance Use with Complications. They also added HCC 56: Substance Use Disorder, Mild, Except Alcohol and Cannabis; HCC 59: Major Depressive, Bipolar, and Paranoid Disorders; HCC 60: Personality Disorders; and HCC 138: Chronic Kidney Disease, Moderate (stage 3).

The 2019 model uses a blended risk score calculation using the version 22 model and the 2019, version 23 model. The EDPS risk scores are calculated using the 2019 model at 25% and RAPS risk scores are calculated using the 2017 model at 75%. Total risk scores are calculated by weighting the EDPS/2019 model risk score at 25% and adding this product to 75% of the RAPS/2017 model risk score. Additionally, we saw rate factor changes and adjustment variables. The coding intensity adjustment was 5.90%, and the normalization factors for PY 2019/V23 were reduced to 1.038 from 1.041 in PY 2017/V22.

To understand the financial impact, here’s an example. A 72-year-old male who is disabled, has type-2 diabetes with chronic complications and congestive heart failure has a 1.328 RAF score for RAPS, V22, and 1.303 for EDPS, V23. With a blended risk score of 1.196, the risk score is lowered by .004 even though the HCCs are the same.

Although the new model will require more work to maintain the same level of payment, you can still use retrospective chart reviews and adjust to the new model to ensure your reimbursement rates do not decrease.


Best Practices for Retrospective HCC Code Capture


You should continue to do the same gap analysis but take into consideration the new HCCs. You can do special targeting or analysis to see which of your members are more susceptible to the diagnoses. For example, if you have a member who was prescribed an antidepressant or a mood stabilizer, if you don’t already have an HCC for depression, you can target those members for a retrospective chart review to potentially capture HCC 59.

You should also take the previous year’s data and run it through the new model. Update your correlation models to include the new HCCs. By doing so, there’s a greater likelihood of capturing the new codes, particularly in cases where you may not have data on a specific member from previous years.

For 2020 PY and beyond, it’s important to keep abreast of the new HCCs every year. When new HCCs are added, it’s always an opportunity to capture those you weren’t capturing previously. Not only will you have to update how you’re looking at your YOY logic, but you’ll also have to consider correlations that you’re doing and update those with the new codes.

What’s more, while payers focus on educating providers to document HCCs, they often forget to emphasize the associated conditions, letting accurate documentation fall through the cracks. This may be due to lack of time, too much focus on other aspects of the visit, or sensitivity around communicating the diagnosis. In the past, one challenge has stemmed from providers who only document depression when major depressive disorder (MDD) was the actual diagnosis. By educating providers to accurately document, you’ll have more success accurately capturing the HCCs.

Provider query is an effective way to retrospectively capture an HCC and educate. It gives the provider specific examples to help them change the way they document the codes moving forward. The provider query can be conducted in two ways. The first is during a concurrent code review. After coders review the medical records, they identify conditions that lack support for accurate HCC capture or missed HCC opportunities. The chart is sent back with a query to the provider to get additional documentation and capture the HCC. Another way is to identify the clinical evidence supporting the opportunity and send it to the provider. At the next appointment, the provider can capture the HCC based on the clinical evidence, or if the condition was partially addressed during a previous visit, they can amend the chart to accurately capture the appropriate HCC.



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