CMS pays Medicare Advantage plans differentially based on Hierarchical Condition Category (HCCs).
This coding model uses demographics and diagnoses to predict future health care costs for Medicare beneficiaries enrolled in a Medicare Advantage plan.
Each year, Medicare announces what the rates will be and indicates any coding changes in the HCC model. Between 2017 in 2018, there were no coding changes to the HCC model.
However, changes proposed in December 2017 and implemented in April 2018 include coding changes for:
- Chronic kidney disease
- Some mental health disorders
- Some substance abuse disorders
Many medical practices are part of an accountable care organization or have risk adjusted contracts with payers. Some of those contracts may use HCCs to estimate the acuity of the patient population. And, others will use proprietary systems.
This article describes the changes to V23 of HCC.
Chronic kidney disease (CKD)
In 2017, CKD Stage 3 N18.3, was not included in the CMS-HCC model. Only Stage 4, Stage 5 and ESRD were mapped to an HCC category.
In 2018, Stage 3 CKD N18.3 will be included in HCC 138, which is defined as “chronic kidney disease, moderate, stage 3.” This includes both Stage 3a and 3b. Stage 3a is based on a glomerular filtration rate (GFR) of 45-59. Stage 3b is a GRF of 30-44.
Mental health disorders
In 2017, CMS-HCC included two categories in the risk calculation, HCC 57 Schizophrenia and HCC 58 Major Depressive, Bipolar, and Paranoid Disorders.
In 2018, CMS is including two additional categories in the payment model.
The first is HCC 59, Reactive and Unspecified Psychosis and the second is HCC 60 Personality Disorders. Conditions in HCC 59 are those that are related to schizophrenia but don’t meet the full criteria for schizophrenia or other related disorders. HCC 60 consists of well-defined personality disorders.
The hierarchy is being reordered and renumbered.
|HCC 57 Schizophrenia||HCC 57 Schizophrenia|
|HCC 58 Major Depressive, Bipolar, and Paranoid Disorders||HCC 58 Reactive and Unspecified Psychosis|
|HCC 59 Reactive and Unspecified Psychosis||HCC 59 Major Depressive, Bipolar, and Paranoid Disorders|
|HCC 60 Personality Disorders||HCC 60 Personality disorders|
In 2017, CMS-HCC recognized two categories related to substance abuse, HCC 54, Drug/Alcohol Psychosis and HCC 55 Drug/Alcohol Dependence. No values were assigned to HCC 56, Drug/Alcohol Abuse, Without Dependence.
In 2018, CMS will add additional diagnosis codes to HCC 55 and rename it Drug/Alcohol Dependence, or Abuse/Use with Complications. Additional diagnosis codes are being added to this category.
HCC 56 will be Drug Abuse, Uncomplicated, Except Alcohol and Cannabis and HCC 56 will be included in the CMS-HCC model.
The other two new HCCs, HCC 202 Drug Use, Uncomplicated and HCC 203 Alcohol Abuse and Cannabis Use/Abuse, Uncomplicated, Non-Psychoactive Substance Abuse, and Nicotine Dependence will be excluded from the model for payment.
As always, pay particular attention to specificity in the code selected for serious chronic diseases, particularly those with a manifestation or complication.
There are many additional articles on CodingIntel about HCC coding, including on demand webinars which members can access free of charge.
The CodingIntel Guide to Hierarchical Condition Categories provides a comprehensive list of HCC and Risk Adjusted Diagnosis Coding resources available on CodingIntel.