HCCs for the Holidays

By Erica Remer, MD, CCDS

If you don’t know what Hierarchical Condition Categories (HCCs) are, you should. It is a risk-adjustment model, which is patient-centered in contradistinction to the encounter-based risk-adjustment inpatient model of DRGs. Diagnoses which impact the HCC model come from inpatient and outpatient encounters, professional and technical billing. Although its most robust use is in population health management and prospective capitation, the HCC model also factors in some quality metrics as well.

The CMS-HCC model is changing for 2020. A fourth component is being added to the risk adjustment score (RAS). In addition to the demographics baseline, the risk adjustment factors (RAFs) of each condition after the hierarchy is applied, and the adjustment for interaction between certain conditions, the number of conditions a patient has will award additional risk adjustment. If a patient has four or more conditions, their RAS will be augmented by an incremental factor. This is referred to as the Alternative Payment Condition Count (APCC).

There are also several new HCCs – HCCs 51 and 52, Dementia with and without complications (behavioral disturbance) and HCC 159, Pressure ulcers with partial thickness skin loss.

Sometimes related HCCs have the same RAF; e.g., Dementia with complications = 0.346 = Dementia without complications. So why split hairs? The RAFs are adjusted yearly; if CMS finds that there is a differential in resource utilization, they may change the RAF accordingly. Best practice is to be accurate. The way I convey my mnemonic is, “I know it’s a hASSLe, but give Acuity, Specificity, Severity, and Linkage.”

If you’ve ever attended a presentation on HCCs, you have likely heard the following:

  • It is important to document diabetes “with hyperglycemia,” because you want the HCC risk-adjustment of “diabetes with chronic complications” as opposed to “without complications.”
  • Ostomies and amputations are important to document and code on a yearly basis, because all diagnoses must be recorded each year.
  • The problem list must be curated and revised to accurately reflect the patient’s current status. Acute problems which have resolved only impact the following year and then should drop off (they may transform into non-risk-adjusting “Personal history of” codes, however).

I have a few more tips for you:

  • Manifestations may provide risk adjustment. For instance, G6PD-deficiency is not in an HCC; anemia due to G6PD-deficiency is (RAF 0.192). Having a stroke lasts for one cycle; it is acute and once resolved, regresses to “Personal history of stroke.” However, hemiparesis due to a cerebral infarction (RAF 0.437) may be captured for as long as the patient manifests it.
  • Conditions which go into and have a code specifying remission should appear in the patient’s active problems. Acute leukemias, substance use disorders, and depression are some examples. If they drop off the radar instead of being marked as “in remission,” the RAF is not captured.
  • Liver disease should be specified with acuity, etiology, and manifestations, like “with coma.” There are HCCs for End-stage Liver Disease, Chronic Hepatitis, and Cirrhosis.
  • It is important to document the duration of loss of unconsciousness in head injuries because this may distinguish between the Severe and Major Head Injury HCCs.

The hierarchy part of the HCC model is that certain conditions nullify lower ranked conditions. For instance, a patient with current lung cancer which has spread to the brain and bone triggers both HCC 8, Metastatic cancer and Acute Leukemia (RAF 2.659) and HCC 9, Lung and Other Severe Cancers (RAF 1.024). HCC 8 trumps HCC 9, and the RAS only incorporates the 2.659 risk adjustment. There is a table which sets out these hierarchical groupings (Last page of Advance 2020 Part 1.pdf).

A little-known fact about HCCs is that there are a few conditions which are found in multiple HCCs and are not nullified because those HCCs are not in a hierarchical grouping. They are usually combination codes which have an etiology and unrelated manifestation. You can claim credit for each. An example of this is:

Diabetes with diabetic peripheral angiopathy with gangrene which is found in HCC 18 Diabetes with chronic complications AND HCC 106 Atherosclerosis of Extremities with Ulceration or Gangrene

You get the 1.488 for HCC 106 PLUS 0.302 for HCC 18. It is because you can predict expenditures due to the diabetes and due to the gangrenous peripheral angiopathy. However, if the patient ends up with acquired absence of the lower extremity (i.e., an amputation), the risk adjustment of the amputation, HCC 189, RAF 0.519 is nullified by HCC 106 due to a hierarchical grouping.

The best advice I can give you regarding understanding HCCs and which conditions your staff needs to focus on is spend time looking at the tables yourself. Vendors may produce software to help manage HCC capture, but it is no substitute for your physician advisor brain.