From yesterday’s CMS April 5, 2011 Announcement, pg. 2:

“Part C Risk Adjustment Model. Based on our interpretation of Congressional intent regarding changes in Part C payment methodology, CMS will not implement the new CMS-HCC and CMS-HCC ESRD dialysis risk adjustment models or the recalibrated frailty factors in 2011. CMS will implement these new models in 2012. To reference the factors in the CMS-HCC risk adjustment model that will be used in 2011, see the 2009 Rate Announcement (published in April 2008). To reference the factors in the CMS-HCC ESRD risk adjustment model that will be used in 2011, see the 2008 Rate Announcement (published in April 2007).”

Link to 2011 Announcement:

http://www.cms.gov/MedicareAdvtgSpecRateStats/AD/list.asp#TopOfPage

I am hearing from several of my readers that the 2011 HCC model codes will implemented starting payment year 2011.  This means that the new code crosswalk (to be finalized April 5th by CMS) will be implemented during the following dates of service windows.  The January 2011 preliminary payment rates will be set by the July, 2009 to June, 2010 12 month dates of service window using the new codes.  The July 2011 payment rates will be set by dates of service in CY2010 using the new codes.

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.

As you have heard, the CMS-HCC Model will change slightly in 2011 with basically some re-organization of ICD-9s into different categories.

Here is a link to the first draft of the codes for 2011.  The final version is expected April, 2010.  This link is to just a numeric crosswalk, I will try to compile a complete file in English in the next few days.

According to the 2009 Risk User Group Q&A session, signature logs are acceptable to use if they were part of the health plan contractual arrangement with that provider during the time of service in question.

Here are the notes from the meeting – see highlights pg.3:  Jan2009_User_group_sig_logs (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

CMS announced in the Oct 22, 2009 Fed Register that they plan to audit 110 MA plans total during the two year period of 2010-2011. All plans will have a 12-week deadline to submit the one best medical record to substantiate an HCC. Typically 700 HCCs will need to be validated on an approximate sample size of 200 patients. Discrepancies will be extrapolated on the plan level for that discrepant HCC rather than as formerly done on the individual beneficiary level.