Here again are the disease interactions that if all components are present give extra credit to a patient’s risk adjustment factor.

DM + CHF 0.154
DM + CVD 0.102
CHF + COPD 0.219
COPD + CVD + CAD 0.173
RF + CHF 0.231
RF + CHF + DM 0.477

DM is diabetes mellitus (HCCs 15-19)
CHF is congestive heart failure (HCC 80)
COPD is chronic obstructive pulmonary disease (HCC 108)
CVD is cerebrovascular disease (HCCs 95, 96, 100, and 101)
CAD is coronary artery disease (HCCs 81-83)
RF is renal failure (HCC 131)

Here is a .pdf file of the PowerPoint presentation on the top 10 HCC coding mistakes that I delivered at the March HCC conference in St. Louis.  Download here. Send me an email if you’d like the PowerPoint file. Feel free to reuse for your purposes.

About 70-80% of the HCCs and their related ICD9s are for chronic conditions that should show some permanence in the claims data due to the fact that they are conditions that do not disappear.

About 20%-30% of the HCC/ICD9 buckets are for either acute conditions or one-time events like a myocardial infarction, cardiac arrest, pneumonia, stroke, burns, or acute trauma that are much less likely to reappear in the next data period. Certainly, patients can have a recurrent event in the next data period, ie another myocardial infarct, or they may experience a related, but new ICD9 diagnosis that can refresh their HCC. So, be sure to factor out the HCCs that have “dropped off” due to the fact that they are typically acute, one time events. So, acute HCCs that have disappeared should prompt the question of what other related diagnoses might be in the charts, but not reported in claims. For example, an opportunistic infection HCC 5, might be PCP pneumonia in one data period, and Candidal esophagitis in a following data period.

Most of the ostomies have an easily identifiable V code, such as V44.1 Gastrostomy Status- for G-tubes, and V44.3 Colostomy Status.  Another common ostomy, Jejunostomy,  is also in the risk-model, and actually is V55.4 Attention to Other Artificial Opening of the Digestive Tract.

The only “ostomy” that is not in HCC 176, is Tracheostomy which maps to HCC 77.  There are ten ICD-9 codes that map to HCC 77, all are variations on the theme of trach status or ventilator status.  HCC 77 is the second-most ”costly” condition category (for 2009 – first is HCC 7 Metastatic Cancer and Acute Leukemia 2.276) - the presence of HCC 77 single-handedly adds + 1.867 points to a patient’s individual risk adjustment factor.

The CMS risk model gives credit for any type of vertebral fracture, whether it be traumatic (ICD-9 805.x or 806.x) or simply a pathologic, compression fracture – 733.13 – due to an underlying condition such as osteoporosis.  Any type of vertebral fracture maps to HCC 157.

A look at the most recently updated list of acceptable ICD-9 codes for each payment year reinforces CMS’ intention to make sure from now on that acceptable ICD-9 codes are also “valid” ICD-9 codes, i.e. not the incomplete or so called “truncated codes” that were accepted  in previous years.  All of the acceptable ICD-9 codes for HCCs in payment year 2009 are not truncated with the exception of a single truncated ICD-9 code, namely 337.0 Idiopathic Peripheral Neuropathy – this may just be an oversight as CMS intends to not use truncated codes going forward, so it would be best to carry the 337.0x to its fifth digit, either 0,1, or 9.

You can always find the current model diagnosis codes at cms.gov, then search for “Risk Adjustment” in the search box on the top right corner.

The CMS-HCC model is not limited to chronic diseases.  There are a number of traumatic conditions in the model, including skull fractures – HCC 154, and HCC 155.  As well as third-degree burns, HCC 150.  For a burn to be included, it must be at least 10% surface area AND 10% third-degree burn. 

HCC 148, HCC 149 in the skin disease group is a good example of how it may be helpful to know the HCC hierarchy.  In this case, Chronic ulcers HCC 149 is trumped by HCC 148 – pressure ulcers (changed in 2009 from “decubitus” ulcers).  So, a patient with a well-documented pressure ulcer already has the most-valued HCC code in the Skin Disease Group hierarchy, so it would not be efficient to look for or code for HCC 149 as well as it would be canceled out by the HCC 148 during that date of service data collection period.

Addendum (4/21/09) HCC 150 burns can be co-reported with HCC 148 or HCC 149 ulcers.

Dementia has both RxHCC and HCC value.  However, only dementia that is specifically drug or alcohol-induced has HCC value and is mapped to HCC 51.  All of the other forms of dementia, i.e. presenile or vascular, map to RxHCC codes 59 or 60.

 I rarely see a primary care physician precisely label their patient’s form of dementia, as many may be unaware of the criteria needed to make a precise diagnosis.  Often, you will see “Dementia” or “Dementia, NOS” in their assessments.  Dementia NOS is actually ICD-9 294.8 - ”Other Persistent Mental Disorders Due to Conditions Classifed Elsewhere”.  This ICD-9 maps to RxHCC 60 and does not require a “code first” code.

A diagnosis of Acute or Unspecified Hepatitis B or Hepatitis C has no HCC value.  Thus far, only chronic hepatitis B and C have been mapped to hierarchical condition categories in the current version of the CMS-HCC payment model.  I keep seeing merely “Hep B”or “Hep C” in provider progress notes with no mention of whether acute or chronic.  While, as an auditor with the chance to view the entire chart, I might be able to infer whether it is acute or chronic, a CMS validator with just the “one best record” to audit, will not be able to make that inference and thus will likely not be able to substantiate the ICD-9 code.  Make sure your providers are well-versed on the criteria for diagnosing chronic hepatitis B or C and to document their findings appropriately.

One of the biggest lessons I have learned from doing Medicare risk-related chart reviews is that doctors and the people who create ICD-9 terms often do not use the same common terminology.  Doctors so often use synonyms  that you might only see in the “extra descriptions” of the ICD-9 codes. A good example is “Unstable Angina”, which we use all the time – and document as well, is buried in the extra description of ICD-9 code “411.1 Intermediate Coronary Syndrome” which is mapped to HCC 82 and RxHCC 92. A majority of doctors and providers are more likely to document “unstable angina”, so be sure that your coders doing chart audits are aware that many risk-related ICD-9 codes are at times better found by using the Volume 2 alphabetic index.