HCC Coding and Drawing Lines | HCC Coding Tutorial
November 1, 2019
Q: (HCC Coding Lines) You talked about drawing
lines before when doing HCC coding. Can you give me an example of how to do that?
A: Well, you bet I can. So, we can abstract a case and I’m going to show you how to
do that. I actually found a case and wanted to give you an idea of how to do that… Here’s
our case and
what I did was I highlighted the keywords that we’re going to be looking at. We’ve
got a 65-year old male, he’s on Medicare. What is he being seen for? He is being seen
for a follow up with a backache. So, that is his chief complaint. He is also following
up on hypertension, but it’s controlled with medication. He stated that he had chest
pain, the patient states it goes to the right side of the neck and gets headaches.
No, I’m not going to read all of this, I’m going to just highlight that, otherwise, we’d
be here all day because it was a relatively long case. So, then, as you’re doing the
HCC coding, you’re going to start looking at the HPI – what’s going on. Now, as
I scan through this, this is all about one thing and it’s about GERD; he has reflux
and GERD. The three main things that I’ve seen at
this point is, we have got, for diagnoses, we’ve got a backache, we’ve got hypertension,
and we’ve got GERD. Now, remember the HPI is what the patient is telling the doctor,
pretty much. He has chest pain and he’s got angina that the patient is describing,
as well. Now, the way you draw lines though, is that
next, I’m going to go down to the bottom – I usually work charts backwards anyway
because you’re going to look to make sure it’s a valid signature and stuff like that
– so I’m going to go down here and I’ll say, “What is the doctor saying he is assessing,
or the assessment and the plan is going to be?” We have chest pain, unspecified.
I can draw a line right away because, look, this is excellent, he is running labs. So
my line is telling me that he has a current condition, it’s chest pain, that’s his
diagnosis and here’s the labs to support that this is a current condition. Now, he
has given him a medication, this Dexilant. If you don’t know what Dexilant is, you
need to go and look it up, but it is actually for heartburn. It’s a pump-inhibitor type
medication. They’re going to go ahead and do a cardiac diagnostic test. Now, this right
here gives me a line for GERD. Now, I’m going to scroll back up and I had
already gone through all of this stuff, the Review of Systems and the Exam. The things
that jumped out at me because I’m looking for those diagnoses, he has hypertension;
well he did check his rate and rhythm was regular. That gives me a line. He checked
the carotid arteries – because you do that when there’s anything to do with cardiology
as well as blood pressure. Most all of this stuff is fodder. I don’t need it, I couldn’t
pull anything from that; so I would be skipping that.
He reports cough, wheezing and painful respiration. Well, I just happen to know that when a person
has GERD, some of the signs and symptoms are coughing, wheezing and painful respirations.
Now, if you don’t know that, then you can’t draw that line; but I know that so there we
are. We’re establishing GERD. Shortness of breath when walking – that
doesn’t have anything to do with GERD, but can give me a line for the blood pressure.
And we are not allowed to take the information off here and use it in any other way except
to say he checked it, he checked the blood pressure.
Now, let’s say his blood pressure was 218 over 179, even though we know that’s high
blood pressure, we aren’t able to come to that determination. We are not a physician,
that’s not our job. What our job is say, “Look, he checked the blood pressure, and
got a result” so there’s a line. Now you can even go in so much as, “Look, he took
the time to take a family history and there is hypertension and heart disease, all kinds
of stuff going in.” If he had something other than heart disease or some kind, that
would be your line. Now, here, we also see GERD, yes. He’s got
a past medical history of GERD as well as back problems. So, as I’m going up, I’m
not seeing anything until I get into the medications, which is an excellent place to draw your line.
What is this particular medication? I just happen to know that cyclobenzaprine is a muscle
relaxant; if you don’t know that, then you need to go to, like, drugs.com. This, I happen
to know that Dexilant is a pump inhibitor, they give it
to people with heart burn and GERD and stuff. Hydrocodone – that’s a pain medication.
Lisinopril is an ACE inhibitor, people take that for blood pressure. And Lyrica is an
antiseizure medication, but it also is used for people with fibromyalgia or people who
have nerve pain, they’re given Lyrica. So that can draw a line to other diagnoses.
I go back here and I think that’s just about it. When you’re HCC coding, you’re not
coding this document like you’re coding a regular encounter. This encounter is long
gone. So, somebody’s already gone through and coded it. I’m looking for chronic conditions
that are listed, that I can pull to say that this patient is actively being treated for
these chronic conditions, not what was the diagnosis per se, but things that were mentioned.
So, it’s not the same as coding for the reimbursement from the insurance company.
Now, what did I come up with? Well, I came up with only two things that carry HCCs and
that is the GERD and there’s the 530.81 and there’s the ICD-10 codefor it and there’s
the 401.9. Neither one of these carry a regular HCC; however, sometimes you’re contracted
out at certain times to collect not just the HCC but the RxHCC, which literally means they’re
taking medication that MA Plan is having to pay out additional money for the prescriptions
that they’re taking and this carries an RxHCC-68 and one of 187. So those would be
able to be captured, even though the doctor did not say here that the patient had GERD,
you know what I mean? But I can prove that he is actively being treated for GERD and
actively being treated for hypertension. So, that’s how you do it, that’s how you
draw the lines. That is just a little snidbit of what an HCC coder does when they’re abstracting
the information off of an encounter. You would not be looking at just one encounter by itself;
I would have all encounters that this patient had for an entire year. So, there you go!
Again, this is really fun, we have our fantastic course on HCC that not only tells you how
to do this, but it also tells you why you’re doing that, which is even more important.
Just abstracting these diagnosis codes and that knowledge that you get, that’s something
you get with time. But the other information is very heavy, and why do we do this?
Laureen: Before you move off this slide, Alicia, we had probably 20 people say – what is HCC?
So if you could explain that real briefly to help them.
Alicia: It’s Hierarchical Condition Category. You’re collecting codes, you’re collecting
diagnoses for conditions that are chronic, like, diabetes, COPD, any type of diabetic
manifestation, end-stage renal disease, CKD – all of those chronic conditions that caused
the Medicare Advantage Plan’s money. And so, they’re just projecting, when you’re
saying HCC, think chronic conditions. They have a hierarchy in them, some pay out more
money than others because it caused more money to take care of a person that has COPD than
it does for a person that has asthma, or emphysema. You know, somebody that has type 1 diabetes
versus type 2 diabetes, and they’re projecting. Everything that you code for the patients
this year affects reimbursement for next year in this. If everybody is on an MA plan, if
you’re on Medicare, and that’s who is collecting this information is the MA plans.
Laureen: And I just put a link in the chat for you to watch later, but that’s a YouTube
video of Alicia explaining what HCC coding is more at length.
Alicia: It’s very fun stuff. Laureen: That’s an older version, she just
did a new one, but go ahead and start with that and stick with us and you’ll hear more
about it. We’re real excited about the HCC front.
Alicia: Very good. Just as we’re going into the next slide, I wanted to mention that for
being hired as an HCC coder, it comes in waves because they have three pulls a year, especially
at the end of the year, they always panic to get everything coded and out to the MA
plans. So, some places you work all year long and in another contract you might work 3 or
4 months at a time and then have a month off, just so you know.