Interesting Provider Questions!

Here are some frequently asked questions that have been coming up in conversation with our providers recently.


Why do I have to write out my diagnosis when I put the ICD-10CM code in my note?


Answer: Based on ICD-10CM, Risk adjustment auditing and HCC auditing guidelines, “The assignment of an ICD-10CM code is based on the providers diagnostic statement that the conditions exist.” Without the providers’ statement, we cannot confirm that the code is correct. The ICD-10CM code is a billing code, not a diagnostic statement and the accuracy must be confirmed through written documentation.


How will my code assignment affect the reimbursement?


Answer: So many changes are happening with regards to provider reimbursement: Hierarchical condition categories (HCC), Risk adjustment factor scores (RAF), MIPS and MACRA are changing the physician reimbursement landscape.


What do all these acronyms stand for and why should I care?


Answer: HCC-Hierarchical Condition Categories. CMS has been using this reimbursement methodology for Medicaid and Medicare managed care plans since 2003. It was mandated in 1997 and implemented in 2003. HCCs identify individuals with serious or chronic illnesses. When calculated with other socioeconomic factors a RAF or risk adjustment factor[1] is determined. Based on this number CMS estimates the cost of care for the beneficiary. This calculation is repeated each year. The amount calculated is the amount that CMS reimburses the insurance company for the beneficiary. If the actual cost of care is more, the insurance company incurs a loss, if the actual cost of care is less, they make a profit.


Fast forward to 2015 and the Affordable Care Act, MIPS, MACRA and Value Based reimbursement. These are budget neutral plans; payments for strong performers will not affect the budget so low performers will be penalized in order to reward high performers.


What’s an example of how I should document and code properly for value-based reimbursement?


Answer: A patient with Hypertension and Chronic congestive Heart failure, comes in for a BP check and refill on BP medication. After you are done, the patient tells you they have been feeling tired lately. You decide to order an Echocardiogram to evaluate the CHF. You list the diagnosis as Hypertension or I10. This code does not link to an HCC, the cost of care would not equal what is necessary for hypertension and you would not be considered a strong performer. The correct codes would be Hypertensive heart disease with heart failure I11.0 and Chronic Heart Failure I50.




[1] RAF= (Actual Performance over Expected performance) * National Average

A ratio that is greater than one indicates that the provider performed worse than expected, given the provider’s attributed beneficiaries’ clinical complexity, whereas a ratio that is less than one means that the provider performed better than expected, given the provider’s attributed beneficiaries’ clinical complexity. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2015-RiskAdj-FactSheet.pdf

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