For those who have not had a chance to see the 2012 Advance Notice, released by CMS on Feb 18, 2011, there is guidance that CMS does not intend to change the standard HCC model as they had previously announced.  This means that for the non-ESRD models, i.e. the regular Community model, the same HCCs and hierarchy logic will be used for Dates of Service 2011 and 2012 payment.

It appears that the ESRD model will incorporate the new HCCs.  See the Advance Notice for more details.  PDF below.

Advance2012

I did a quick comparison of the ICD9s in the current  2010 Payment Year HCC-ICD9 crosswalk to the ICD9s mapped to the preliminary release of the 2011 CMS and found about 250 “newly added” ICD-9 codes that are not in previous models.  Again, this is a prelim release, so treat this file as an FYI that may change.  On tab 2 of the excel are the 100 or so ICD9s slated for deletion for PY2011.  Say goodbye to everyone’s favorite “412 Old Myocardial Infarction”.

2011_HCC_changed_ICD9s(PRELIM) XLS (excel)

Been getting lots of questions lately on which ICD-9 code sets are valid for a particular payment year.  CMS issued guidance on this in their 2009 Advance Notice.

“Starting with payment year 2009, RAPS will only accept valid ICD-9-CM codes for two fiscal years — the fiscal year that begins prior to the payment year and the fiscal year that begins during the payment year — for the CMS-HCC, ESRD, and RxHCC risk adjustment models. For example, for diagnoses codes to be used in 2009 final payment, i.e., for diagnoses from service dates between January 1, 2008 and December 31, 2008, RAPS will only accept codes that are valid for Fiscal Year 2008 and Fiscal Year 2009. (Please note that for the initial risk score run for payment year 2009, CMS will use valid diagnosis codes from FY 2007 and FY 2008 — services dates between July 1, 2007 and June 30, 2008.)”

Advance2009 PDF

Wow, after looking at the 2011 Advance Notice and the prelim 3,090 ICD-9 codes in the 2011 HCC model it is apparent that there are several new HCCs for 2011.  The diabetes group is curtailed from 5 HCCs down to 3.  Dementia HCCs were added.  Pressure Ulcer HCCs (4 of them) were added.

Here are some prelim files for your information – final 2011 model to be finalized in April.

CMS-HCC Model 2011 (PDF – shows HCC revisions)

2011_HCC_ICD9 (XLS – shows 3090 ICD9s mapped to HCC, second tab is the 87 HCCs in the 2011 model- I created this file by crosswalking the 3,090 ICD9s in the prelim model to their English descriptions for 2010 ICD-9 codes.  The second tab is an excel I extracted from the 2011 Advance Notice pdf.

Starting with Payment Year 2009, CMS will no longer accept truncated codes for HCC credit into the RAPS database.  A truncated code is used in the coding books as a “header” to signify more specific codes that follow.  A truncated code is described as an ICD-9 code that is missing its intended final digit.  For example, all diabetes mellitus codes should be a five digit ICD-9 code.  If a provider submits just four digits 250.0, for example, this will no longer map to a diabetes HCC.  Many claims clearinghouses and practice management software will scrub provider claims and flag these incomplete codes.  Health plans vary on whether or not truncated codes are acceptable to justify the procedure or E/M encounter.  These truncated codes then represent HCC conditions that might not get captured, so it is important for a plan to get a sense of whether or not truncated codes are worth looking into.  For patients who are seen infrequently like once or twice a year, a truncated code may represent the only claim for diabetes from an acceptable provider.

Most HCC educators will preach to doctors and providers to be “as specific” as possible when coding.  However, most providers do not make the connection between being “more specific” and submitting codes to their final digit.  So, educators should be explicit that some ICD-9 codes in the book are not valid because they are just headers, and that if a “longer” code with more digits exists under a heading, then that is the one that should be used.

For the most part, the diseases that have been mapped to Hierarchical Condition Categories (HCCs) represent chronic conditions that will persist from one data period to the next, for example, Diabetes, COPD, End-stage liver disease, etc. About 17 of the HCCs represent transient conditions that are likely to resolve in a matter of days or weeks and therefore not persist from one data period to the next -i.e. won’t be present year over year. Under these “transient” conditions, I am lumping one-time events, like Respiratory Arrest. Therefore, the disappearance of transient HCCs does not necessarily represent “code drop off”.

Here are the HCCs that are likely to be transient, such as acute or subacute conditions.
HCC 2: Septicemia, shock
HCC 5: Opportunistic Infections
HCC 17: Acute complications of Diabetes, such as DKA
HCC 21: Protein-Calorie Malnutrition ( could be long term )
HCC 31: Intestinal Obstruction
HCC 37: Bone/Joint/Muscle Infections
HCC 51: Drug/Alcohol Psychosis
HCC 78: Respiratory Arrest
HCC 79: CardioRespiratory Failure and Shock
HCC 81: Acute Myocardial Infarction
HCC 82: Unstable Angina
HCC 95: Cerebral Hemorrhage
HCC 96: Stroke
HCC 111: Pneumonias
HCC 112: Other Pneumonias, abscesses
HCC 154: Severe head injury
HCC 155: Major head injury
HCC 157: Vertebral Fractures

Add: 11.5.2010

These also are likely not chronic, can be acute or sub-acute (months)

HCC 75 Coma, Brain Compression/Anoxic Damage

HCC 148 Decubitus Ulcer of Skin

HCC 158 Hip Fracture/Dislocation

HCC 164 Major Complications of Medical Care and Trauma

I frequently get questions about whether or not the CMS RAPS system will accept only part of a “code pair” towards a patient’s risk score.  For example, if the ICD-9 for Diabetes with Renal manifestations (HCC 15) is submitted without an appropriate secondary code showing the renal manifestations, such as the ICD-9 for nephropathy (HCC 132) or the ICD-9 for Chronic Kidney Disease (HCC 131).  When I look at the SAS source code for the risk-adjustment score calculation software provided by CMS, I do not see any logic there at all that would reject the primary code if the secondary code is absent.  In other words, I believe the answer is yes, that the CMS RAPS model will accept HCC 15 even though no appropriate secondary manifestation code has been submitted.  This can be verified by a plan looking at its monthly MOR report and seeing a member with an HCC 15 without an associated HCC 131 or HCC 132.  This then represents a tremendous opportunity to identify providers who are not coding manifestations.

Here are some files showing the 2010 HCC and RxHCC codes:
The truncated codes are indicated by an “*” and are not valid for payment

Original File from CMS – 2010 Model xls

File showing 2009 and 2010 Codes only xlsx

File showing just new ICD9 codes in HCC model for 2010 xls

The HCC codes/categories in the CMS-HCC 70 Model will stay the same when the new 2010 ICD-9 codes roll out in about a month on October 1st. Looking at the new codes, I only see a handful of new ones that CMS might add to the HCC-ICD9 crosswalk, possibly Merkel cell carcinoma and some new chronic deep vein thrombosis codes. CMS typically publishes a spreadsheet of the new crosswalk during the first week of October and I will post it on the blog when available.

The risk factor values, i.e. the score that each HCC is worth, are not expected to be recalibrated until the 2011 payment year, so they should be the same for 2010 as they were for 2009.

Be sure to use the Acute MI ICD-9 codes 410.xx for the diagnosis of an acute Myocardial infarction.  These include the initial episode of care, and subsequent episode of care 5th digits.  HCCs 81,82,83 cover new MI, angina, and old MIs.  Try to specify initial episode of care when that is clearly documented- these will map to HCC 81. If the episode is a subsequent episode of care or unspecified it will map to HCC 82.  The risk score for HCC 81 or HCC 82 is just a little higher for HCC 81, but is essentially the same as HCC 82.  Old MI code 412 maps to HCC 83 and is used 8 weeks after a diagnosis of MI.