Risk Adjustment

How to Identify and Apply ICD-10 Combination Codes to Improve Medicare Risk Adjustment ROI in 2019 and Beyond

Written By
Tim Buxton
Director of Coding Services

There’s no doubt Medicare Advantage plans and other risk bearing entities have heard about ICD-10 combination codes, but with the increased amount of single ICD-10 codes over the past few years, it’s crucial that they understand why and how to assign them. Since they play a significant role in coding and risk adjustment, they’re key to close HCC gaps, receive reimbursement in a timely manner, and reduce costs.

Yet what are combination codes? And how do payers sift through the increasing amount of new ICD-10 combination codes, HCC codes and coding clinics released each year to implement the changes concurrently and retrospectively? We have some detailed insight.


What are ICD-10 Combination Codes?


ICD-10 combination codes allow payers to report a single code which includes multiple characteristics of the diagnosis.

According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2019, a combination code is a single code used to classify:

• Two diagnoses, or
• A diagnosis with an associated secondary process (manifestation)
• A diagnosis with an associated complication

In 2019, there were 279 new codes, 143 revised codes, and 51 deleted codes released by CMS and the National Center for Health Statistics (NCHS).

Rather than assigning multiple diagnostic codes, it’s crucial for payers to use single combination codes to accurately represent the patient’s condition and receive the higher RAF value. Since RAF scores for patients who are assigned ICD-10 combination codes can be as much as 5 times the amount of RAF and the associated bump in reimbursement, it’s crucial they use the appropriate combination codes to accurately represent their patients’ conditions.

Here are two examples of combination codes and how they can affect RAF scores.


Example #1
Vascular Disease


HCC 106 – Atherosclerosis of the Extremities with Ulceration or Gangrene (RAF value 1.588)


HCC 108 – Vascular Disease (RAF value .327)

Codes that represent vascular disease, mapped to HCC 108.

I70.201 Unspecified atherosclerosis of native arteries of extremities, right leg
I70.202 — left leg
I70.203 — bilateral legs
I70.208 — other extremity
I70.209 — unspecified extremity

I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
I70.212 — left leg
I70.213 — bilateral legs
I70.218 — other extremity
I70.219 — unspecified extremity

I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg
I70.222 — left leg
I70.223 — bilateral legs
I70.228 — other extremity
I70.229 — unspecified extremity

If an ulcer develops due to atherosclerosis, the following combination codes are used. As you can see, the combination codes represent both the underlying cause (atherosclerosis) and the manifestation (ulceration). The following codes yield HCC 106:

I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 — of calf
I70.233 — of ankle
I70.234 — of heel and midfoot
I70.235 — of other part of foot
I70.236 — of other part of lower right leg
I70.239 — of unspecified site


If a coder does not use a combo code and simply codes Vascular Disease from HCC 108 and an ulcer from the L-codes, you will not get the higher RAF value for HCC 106. These combination codes must be used specifically.


Example #2
Substance abuse / psychosis


HCC 54 – Substance Use with Psychotic Complications (RAF value 0.564)


HCC 55 – Substance Use Disorder, Moderate/Severe, or Substance Use with Complications (RAF value 0.283)

HCC 54 is worth approximately double the RAF score of HCC 55.

Codes that represent substance use disorder, mapped to HCC 55:

F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.129 Alcohol abuse with intoxication, unspecified

Codes mapped to HCC 54:

F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions
F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations
F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified


If single codes for “alcohol abuse unspecified,” “delusions,” “hallucinations,” or “unspecified psychosis,” are used individually, it will not trigger the more valuable HCC and subsequent reimbursement.


Clinical Value


Accurately identifying and applying combination codes can also trigger disease management programs, which can help educate members about their conditions and provide interventions that prevent higher costs associated with caring for a riskier member. Diet and exercise counseling, enrollment in support groups, assistance in scheduling specialist appointments to treat specific issues, transportation assistance to medical appointments and enrollment in a Silver Sneakers or a similar exercise program are all examples of these kinds of programs and interventions. When successful, they can prevent complications from progressing unchecked and save millions of dollars in hospital care.


Best Practices for a Complicated Process


ICD-10 coding is challenging in and of itself, but with combination codes specifically, there are several guidelines and standards regarding which codes can be used—and which cannot—as well as quarterly updates from the American Hospital Association’s Coding Clinic that provide detailed instructions on how to properly apply the codes. When it comes to providers, some aren’t aware that combination codes exist and for those who do, they simply don’t have the time to search for and identify the right ones. Therefore, implementing the changes concurrently and retrospectively is a complicated, challenging process.


Have a Coding Expert

Since the new ICD-10 codes and the HCCs are released once a year, and the coding clinics are released quarterly, it’s important that payers have one or more experts on staff who specifically deal with risk adjusted ICD diagnostic coding. These SMEs should understand how to execute retrospective projects that take into account the new codes and the corresponding risk adjustment model.


Evaluate Records

Payers also need to use coders and/or an NLP-enabled software to identify which records they will review to identify the ICD-10 combination codes. Then they can determine whether or not those combination codes have been applied.


Provide Ongoing Education for Providers

Since identifying and applying the ICD-10 combination codes is crucial for reimbursement, payers must educate their providers on how to get it right at the source. Providers should consistently be educated on the combination codes and updates, as well as how to properly document and assign the codes.

Utilizing a provider query can help payers identify areas in which a provider’s documentation tends to be weak or confusing. Since providers are busy caring for patients, payers should focus on—and customize— their education for their providers. It’s always more effective to be able to present a copy of the provider’s own documentation as an opportunity for improvement, instead of focusing on abstract suggestions.


At Episource, we’re here to help you track and review your analytics throughout the year. Learn more about our risk adjustment solutions or talk to one of our experts today to discover how we can help optimize your year-round analytics program.


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