decisionhealth Newsletters, Coder Pink Sheets - 2013 Issue 8 (August)
Managed care: Prepare for HCCs and new emphasis on diagnosis codes from ACA plans
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Article Overview
This article covers hierarchical condition classifications and their role in risk-adjusted payment for Medicare Advantage and ACA exchange plans. It is aimed at physicians, practice managers, coders, and revenue cycle staff who need to understand how diagnosis coding, documentation, and payer audits are affected by these payment models. The article also discusses the broader operational impact on practices and includes an illustrative HCC diagnosis code list example.
Why This Topic Matters
Risk-adjusted payment models place greater emphasis on accurate diagnosis coding and documentation, which can affect audits, reimbursement, and administrative workload for provider practices.
Article Sections
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HCCs selected based on diagnosis coding
This section introduces hierarchical condition classifications and explains their role in risk-adjusted payment models. It also compares them with other diagnosis-based payment groupings and describes how annual condition assessment and documentation fit into the process.
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More audit requests in your future
This section addresses the operational impact of managed care auditing and documentation demands on physician practices. It also discusses expected changes associated with ACA exchange plans and related payer review activity.
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Example of a hierarchical condition category (HCC): hip fracture
This section presents an illustrative HCC example with a diagnosis code list tied to a specific condition category. It shows how grouped diagnoses are represented within a risk-adjusted payment framework.
What You Will Learn
- How HCCs relate to diagnosis-based risk adjustment in managed care
- Why documentation and diagnosis coding matter more under risk-adjusted payment models
- What operational effects payer audits can have on provider practices
- How ACA exchange plans are discussed in relation to HCC-based methodologies
- How an example HCC diagnosis category is organized
Who Should Read This
- Physician practices
- Medical coders
- CPCs and CCS-certified professionals
- Revenue cycle managers
- Practice administrators
- Managed care billing staff
Codes Discussed
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