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HCC Coding Audit

Risk adjustment auditing and provider education is a required element in our gain-share methodology for Innovation Health.  The goal is to educate the providers on the link between the financial benchmark (expected cost of care) and value-based payments (gain-share).  This year Signature Partners quality team collaborated with the Inova Professional Billing Office to complete the auditing of its network providers. Our goal was to audit 90% or more of adult primary care providers with at least 50 or more active Innovation Health members attributed to the practice TIN at the end of the first quarter. The team reviewed 330 encounters for 110 providers for documentation of chronic conditions. Feedback was provided to the practices for the opportunities to improve Hierarchical Condition Category (HCC) coding as well as Evaluation and Management (E&M) coding accuracy and gaps in evidence-based care for patients with diabetes, heart failure, and COPD. Some of the opportunities identified in regards to HCC coding include:

  • Primary diagnosis not listed in the first position
  • Documented chronic conditions/diagnoses not reported
  • Use of ICD10 ending with “9” when progress note clearly specify the definitive diagnoses
  • Codes for patient’s noncompliance are not being utilized
  • Risk factors are not being coded; e.g. obesity and tobacco use

Signature Partners will continue to be a resource for HCC coding education for our providers.

Coding Corner

Medicare began paying for advance care planning services on Jan. 1. As with most new reimbursement programs released by the Centers for Medicare & Medicaid Services (CMS), physicians have had questions. Last week, CMS attempted to answer some of them.

Advance care planning services are described by two Current Procedural Terminology (CPT) codes:

  • 99497, Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
  • +99498, Each additional 30 minutes (List separately in addition to code for primary procedure).

Among the highlights in the CMS’s answers:

  • CMS will follow CPT provisions regarding minimum time required to report the service; that means a unit of time is attained when the mid-point is passed.
  • CMS has not established any frequency limits for these services.
  • There are no place of service or physician specialty limitations on the codes.
  • Medicare administrative contractors will determine any documentation requirements.
  • Completion of an advance directive is not required to bill the service.
  • Advance care planning can be reported in addition to other evaluation and management services, except certain critical care services.
  • No specific diagnosis code is required with advance care planning codes.
  • These services are subject to the usual Part B deductible and coinsurance unless furnished as an optional element of the Medicare annual wellness visit.

For additional information, CMS encourages you to read pages 70955-70959 of the final rule on the 2016 Medicare physician fee schedule and Medicare Learning Network Matters article MM9271.

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