Depression coding and Hierarchical Condition Coding (HCC)

Introduction | Depression coding in HCC

In fee-for-service medicine:

Diagnosis coding establishes the medical necessity for a service. At times, it may be the reason for a denial, particularly for diagnostic tests or procedures.  Services with national or local coverage policies often have specific diagnosis codes that are required for payment.

In risk based contracts or Accountable Care Organizations (ACOs):

Payers assess the acuity of a panel of patients, and use that acuity along with age/gender distribution, cost, quality and outcomes, to provide incentive payments or decrease payments at the end of a contract year.

What should physicians and other practitioners do?

Follow ICD-10 rules. The General Guidelines for outpatient visits say, “Code all documented conditions which exist at the time of the visit that require or affect patient care or treatment.” If the patient’s underlying medical problems that require or affect treatment, document them in the assessment/plan and use those codes on the claim form.

For example, a surgeon sees patient with kidney disease, diabetes and heart disease, and sends the patient for pre-op clearance.  The patient’s underlying medical conditions affect the surgeon’s treatment of the patient.  The surgeon should report these underlying conditions that affect the patient’s treatment. Of course, this needs to be documented in the assessment and plan and show the surgeon’s clinical thinking.

CodingIntel members can download the entire Risk Based Diagnosis Coding (Billing Guide) for more explanation and examples.  This article is specific to depression.