DOB: 07/28/1963 Appt. Pertinent Guidelines • Payment Methodology • CMS HCCs, HHS HCCs, CDPS, etc. All other codes listed that are not in blue font will have no impact on the Risk Adjustment score. The CPT, HCPCS, and ICD-10 codes listed below are not exhaustive. ICD-10-CM guidelines, Coding Clinic guidelines, CMS guidelines). Each HCC has its own relative Risk- conducts HCC diagnosis coding and documentation reviews to ensure accurate HCC data reporting. These HCC reviews are part of Moda Health’s quality review program. Hierarchical condition category (HCC) coding is a risk-adjustment model designed to estimate future health care costs for patients. HCC Coding Definition Hierarchical Condition Category (HCC) is a risk adjustment model implemented by CMS in 2004 to estimate predicted costs for Medicare beneficiaries based on disease and demographic risk factors or simply, the category of medical conditions that map to a corresponding group of ICD-9 diagnosis codes. • HCC reviews apply standard diagnosis coding and documentation guidelines (e.g. (monitoring, evaluating, assessing and treatment) in the medical record: - Monitoring signs, symptoms, disease progression, disease regression o New diagnoses, chronic conditions or suspected conditions 2020 Annual Wellness Visit (AWV) Coding and Documentation Tips Use the following CPT and/or ICD-10 codes in your claim form as appropriate for the service(s) provided. A code can map to more than one HCC as ICD-10-CM contains combination codes (i.e., one code can represent two diagnoses or a diagnosis with a complication). Risk Adjustment Models •Disease groups contain major diseases and are broadly organized into body systems •HCCs (Hierarchical Condition Categories) Medicare •HHS-HCC (Health & Human Service’s Hierarchical Condition Categories) Marketplace •CDPS+Rx (Chronic Illness and Disability Payment System) Medicaid •HCCs allow for payment for only the most severe or complicated This model will be used in calculating a Medicare Advantage (MA) member’s blended However, because Rx HCC conditions are frequently treated they do have a significant impact on the overall Risk Adjustment score. CMS HCC model • 25 condition categories • 79 HCCs • 8,830 ICD-10 diagnosis codes An HCC is a category of disease type (e.g., congestive heart failure) with multiple individual ICD-10 diagnoses that map to that HCC category. • Sub models • Rate year risk factors & mapping tables • Code Sets • ICD-10-CM • Official Coding Guidelines • Coding Conventions • Official Coding Guidelines published by the National Center for Health Statistics 2020 CMS-HCC Risk Adjustment Model (Version 24). HCC 8 Metastatic Cancer and Acute Leukemia 2.654 HCC 9 Lung and Other Severe Cancers 1.027 HCC 10 Lymphoma and Other Cancers 0.675 HCC 11 Colorectal, Bladder, and Other Cancers 0.309 HCC 12 Breast, Prostate, and Other Cancers and Tumors 0.153 HCC 17 Diabetes with Acute Complications 0.307 Risk Adjustment Coding and HCC Guide 2018 Optum360, LLC 59 Coding Scenario 1 Patient Name: Betty Smith Electronically Signed: Dr. B. Johnson, D.O. Date/Time: 4/5/2017 Insurance: Medicare Advantage (HMO) Appt. 2020-2021 Medicare Advantage Annual Wellness Visit Guide ... (HCC) coding by documenting M.E.A.T. Abdomen Imaging Guidelines Abbreviations for Abdomen Imaging Guidelines 4 AB -1: General Guidelines 6 AB -2: Abdominal Pain 12 AB -3: Abdominal Sepsis (Suspected Abdomin al Abscess) 23 AB -4: Flank Pain, Rule Out or Known Renal/Ureteral Stone 25 AB -5: Gastroenteritis 29 AB -6: Mes enteric/Colonic Ischemia 31 The AWV form and instructions are not templates for CPT, HCPCS, or ICD-10 code selections.
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