Risk adjustment is the process of modifying payments and benchmarks to reflect the degree of illness in a specific patient population. For the Medicare Shared Savings Program (MSSP), the Centers for Medicare & Medicaid Services (CMS) uses a risk adjustment methodology called Hierarchical Condition Categories (HCCs), the same methodology used for the Medicare Advantage program.
HCCs are derived from ICD-10 codes through a retrospective review of claims data. CMS recognizes 79 HCCs, each tied to a chronic health condition likely to affect long-term health expenditures. Each HCC is mapped to several ICD-10 codes, although less than 15% of all ICD-10 codes are mapped to an HCC. CMS assigns a weight to each HCC, representing the predicted impact of that condition on a beneficiary’s total cost of care.
For an accountable care organization (ACO) participating in the MSSP, having a higher overall risk score translates into a higher benchmark for expenditures, while a lower score means a lower benchmark. Thus, if ACO providers do not list all pertinent diagnoses on their claims due to inadequate documentation or coding errors, it will be more difficult for the ACO to achieve shared savings.
To that end, many ACOs educate providers regarding HCCs and appropriate documentation and coding. But recent enforcement actions involving Medicare Advantage plans’ schemes to increase HCC scores are a caution against overly aggressive initiatives.
On August 4, the federal government intervened in a lawsuit against Cigna brought by a whistleblower under the False Claims Act. The complaint alleges Cigna incentivized providers to perform “enhanced” annual wellness visits for Medicare Advantage beneficiaries to boost risk scores and thus increase Cigna’s monthly capitated payments.
Earlier this year, the Department of Justice filed a lawsuit against Anthem under the False Claims Act, alleging the company knowingly failed to delete inaccurate diagnoses codes submitted to CMS for Medicare beneficiaries covered under Anthem’s Medicare Advantage plans.
Both Cigna and Anthem intend to vigorously defend their actions. But these enforcement actions are an excellent reminder that HCC initiatives must focus on complete and accurate documentation and coding, not merely capturing more ICD-10 codes on claim forms.
A diagnosis code should be listed on the claim form for a patient encounter only if it meets the MEAT test, i.e., the medical record documentation indicates the condition is being monitored, evaluated, assessed/addressed, or treated.
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- Monitor – signs, symptoms, disease progression, disease regression
- Evaluate – test results, medication effectiveness, response to treatment
- Assess/Address – ordering tests, discussion, review records, counseling
- Treat – medications, therapies, other modalities
Merely noting the patient has a history of a certain condition—with no MEAT on the bones—is not sufficient to include the corresponding ICD-10 code on the claim form.
CMS regularly provides each MSSP ACO a report showing the ACO’s HCC rates per 10,000 beneficiaries as compared to all MSSP ACOs’ rate. An ACO with significantly lower HCC rates likely has a significant opportunity to help providers improve documentation and coding accuracy. This work can benefit the ACO by increasing its benchmark in later years, and better prepare providers for success under other value-based contracts. It also can identify and close gaps in patient care, improving quality and outcomes.
At the same time, an ACO with above-average HCC rates should approach any such initiative cautiously, as CMS could interpret such work as an attempt to game the system. Your ACO’s compliance officer should be directly engaged in vetting any documentation and coding program to avoid the appearance of any impropriety. Pay careful attention to messaging; avoid leaving providers with any impression their performance will be measured by HCC scores.
PYA provides practical documentation and coding training for providers and staff, performs compliance audits relating to HCC coding, and helps ACOs develop and maintain effective compliance programs. For more information, contact one of our PYA executives below at (800) 270-9629.
