By: Valentina Gallegos, BA, CPC, CRC
Hierarchical Condition Categories and YOU
- Specific ICD-10-CM codes map to specific Hierarchical Condition Categories (HCC’s)
- HCC’s (Hierarchical Condition Categories) are additive, increasing the patients RAF score and translating the patient’s acuity and complexity
- HCC values along with patient demographics and health status equate your patient’s RAF score
- Every .01 increase in RAF is worth $900-$1,000 increase in patient cost
- HCC’s and RAF scores share the acuity and complexity of patient’s health status with Payer and CMS who provide funds for the patient’s care (for the next year)
- Patient’s medical chart is WIPED CLEAN every year therefore all HCC’s must be recaptured every year!
Example:
- ICD-10-CM Code E11.59 (Type 2 Diabetes with circulatory complications) maps to HCC 18
- HCC 18 value is .305
- In simple terms E11.59 = HCC 18 = HCC Value .305 = $3,000
Tally them up!
- The Risk Score for each chronic disease are tallied to determine the enrollee’s raw HCC RAF score
- Also factored into the final RAF Score is a calculation based on the number of individual HCC’s classified to a beneficiary
- This is called the Payment Condition Count (PCC)
- An additional factor is additive in a patient with a higher number of HCC’s (4 or more)
- Code all HCC’s for your patient AT LEAST ONCE a year!
Coding to the highest level of specificity:
- Improves quality of patient care by addressing the complexity and completeness of each patient each year
- Early detections of disease and slows disease progression by offering CCM and other therapies
- Keeps disease in check!
- Enhances continuity of care when conditions are monitored and assessed
- Reduces ER visits
- Unveils the efforts of all your hard work!
- Allows transparency to other providers treating your patients
- Contributes to shared savings in the network
- Increases patient’s RAF score, translating into your patient’s acuity and complexity to help receive proper funding for the following year, while justifying resources utilized!
