October is often a month of change, be it the weather or the annual rollout of Internal Classification of Diseases (ICD) code additions, removals, and changes. Not as spectacular as fall foliage, perhaps, but just as vital in terms of proper patient-care recording, denial reduction and maximum possible revenue capture.
The 2018 ICD-10 update involved 473 published changes. That included 279 new codes, 143 revised codes and 51 deleted codes. The standout this year is the attention paid to Hierarchical Condition Categories, or HCCs, says Susan Gurzynski-Wells, MS, RHIA, Senior Product Manager, Revenue Cycle, for HealthStream.
“What we’re starting to see is a drilling down into the things affected by HCCs, which means a lot of external codes are expanding,” Gurzynski-Wells says. “In previous years we’ve seen code updates more along the lines of ‘Oops, this didn't’ fall in the particular place where it should,’ and now we’re seeing more code updates in the line of specificity.”
Focus on Hierarchical Condition Categories (HCCs)
The HCC focus has exposed a shortcoming in most healthcare systems. According to a survey performed by the Association of Clinical Documentation Improvement Specialists, “Only 10 percent of hospitals currently possess an outpatient CDI program. However, survey data also shows outpatient CDI is becoming more common; more than 20 percent of respondents indicated that they plan to cover outpatient and/or physician services in the next six to 12 months. Clearly, this is an area of growth and opportunity.”
That means that all patient coding, wherever that patient is seen, will need to be followed carefully in order to ensure coverage determinations and reduce the possibility of denial. It also means that diagnoses around HCCs, which normally fall into the physician-practice arena, now can fall into outpatient CDI more frequently because those patients aren’t just being seen in doctor’s offices. Or, in other cases, those patients aren’t being seen at all.
Coding Oriented More Fully to the Continuum of Care
“The HCC-related coding changes are being done to make sure that dollars being paid to physicians align with making sure that the sicker patients are being treated,” Gurzynski-Wells says. “At the same time, they have to make sure all their patients are documented as well. If you have someone who’s not a good patient, who only goes in when they are sick, If they miss an appointment, they may not be documented that year, and so are not included in that seen-patient list for HCCs. That can affect reimbursement.”
“The best way I heard it explained was when someone said, ‘We’re not a hospital system, we’re a health system that has hospitals.’ We must look at that continuum of care, and make sure that coding is represented all along it. A facility may have great admission volume and a good CMI [case mix index] and still be losing money every month. Because of all the multiple care settings we have now, we have to focus on the documentation and the coding in each.”
The MEAT of the Matter
A sound way of making that happen is through training around the Monitor, Evaluate, Assess/Address and Treat, or MEAT, acronym. HCC documentation should reflect all those areas, and here's how that breaks down:
As with any major shift that includes treatment , documentation and reimbursement, training will be essential. The rise of the physician advisor, a clinically trained doctor who can bridge the gap between documenting for quality and documenting for reimbursement, without losing sight of the importance of each, is one example of how the healthcare community is responding. Those individuals, along with doctors, coders and others, however, will still need to be brought up to speed on ICD-10 shifts around HCCs and any other changes that may come along in future years.
“We have begun to introduce a series of webinars in our nThrive education curriculum and have begun to incorporate the changes into our other curriculum,” she says. “We have changed 86 courses so far, along with many incubators, simulation labs and assessments. We will continue that work so that all the latest ICD-10 changes, especially those around HCCs, are reflected in our materials.”
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