In January 2019, when the new CMS-HCC Risk-Adjustment Model (V23) takes effect, it will include 4 additional HCC categories: chronic kidney disease, moderate (stage 3); drug abuse, uncomplicated, except cannabis; reactive and unspecified psychosis; and personality disorders. Within the new categories, there will also be 83 new HCC codes and more than 9,500 ICD-10 codes.
The new model has the potential to have a positive impact on Medicare Advantage (MA) plans. CMS has stated that the changes are meant to improve risk adjustment by aligning risk adjustment payments to the actual expected costs of care. They also expect the updates to change risk scores at a contract level. With V23 in place, CMS projects it will have a positive effect of 1.1% on risk scores industry-wide and between -2% and 4% for individual health plans.
Yet capturing the new HCC codes will certainly pose challenges for plans. For starters, physician visits and coding will not likely be sufficient to capture the codes. Without access to lab data and EMRs, certain conditions may also be completely off limits. For mental health in particular, it will be necessary to have providers with the knowledge, expertise and training to make the right diagnosis.
Health Risk Assessments (HRAs): The Key To Capture HCCs
Plans that have a solid coding solution in place, understand the new model, and can quickly adapt with a risk adjustment partner, are likely to have the most success capturing the new HCCs. When new changes are implemented, data-driven robust member profiles and in-home HRAs are two key ways that health plans can set themselves up for accurately capturing the new codes. HRAs offer more time with patients to make the diagnosis, more efficiently capture the new HCC codes and close gaps, and increase risk adjustment revenue.
Here are a few recommendations on how to capture the new HCCs at HRAs.
Chronic Kidney Disease, Moderate (Stage 3) (CKD3)
To capture CKD3, providers must have a complete metabolic panel as well as lab data to verify a glomerular filtration rate (GFR) between 59 and 39. With Episource’s custom HRA app, the lab report can be uploaded to the provider’s iPad so they’ll be able to refer to it during the HRA and get a holistic, historical view of the member’s health history that will help to identify and confirm CKD3.
Drug Abuse, Uncomplicated, Except Cannabis
To capture the HCC code, providers must have the DSM-5 criteria to make the diagnosis. Providers should use a screening questionnaire, but they must also be trained on how to differentiate between drug abuse, drug use and drug dependence.
While some PCPs may be able to document this diagnosis, others may need to refer the member to a psychiatrist or other mental health provider since it will probably be out of their scope of practice.
Reactive and Unspecified Psychosis
As is the case with drug abuse, uncomplicated, except cannabis, it’s imperative that the provider understand and be trained on the DSM-5 criteria. Since all of the conditions under this new category look similar and are difficult to diagnose, it requires a provider with the knowledge, experience, and expertise to capture the code. Providers also won’t be able to capture the code without access to the EMRs or paper charts.
At Episource, our clinical services team provides in-home health assessments to help Medicare Advantage, Commercial, and Medicaid plans uncover opportunities and close HCC gaps. To learn more, contact us today.