Documentation and coding for HCCs in the wound care setting

July 12, 2021 / By Bobbie Starkey

As Medicare Advantage (MA) organizations report chronic disease conditions using ICD-10-CM encounter data to the Centers for Medicare and Medicaid Services (CMS) for use in the hierarchical condition category (HCC) risk adjustment program, and CMS validates that the reported conditions comply with federal requirements, we need to understand the importance of documentation and coding to support HCC reporting and compliance with accurate claim submission. 

The Office of Inspector General (OIG) within the Department of Health and Human Services (HHS) recently reported its findings from an MA compliance audit of diagnosis codes that were submitted to CMS for 2015 encounters from one specific MA payer. The audit encompassed a sample of 200 enrollees with at least one diagnosis code that mapped to an HCC for 2015. The independent medical review contractor used by the OIG found that there was no supporting provider documentation for many of the codes that were submitted. This resulted in $197.7 million in net overpayments for 2015. The OIG has recommended the overpayments be refunded. 

How can facilities avoid this scenario? 

Let’s take the outpatient wound care setting as an example. Wound care patients often have multiple conditions that meet HCC risk adjustment reporting. During wound care external audits, I have completed, I find that often the physician’s documentation needs clarification to support an HCC, yet coders do not query for them. We also see challenges when providers perform their own coding and the validation by coding professionals is lacking.

Physicians often do not clearly and consistently document the type of wound that is being treated throughout the wound care treatment period. The terms wound, ulcer, dehiscence and amputation site are often interchanged during an individual visit or from visit to visit in the wound care series. Each of these conditions has a different ICD-10-CM code and not all of them are HCCs. It is also important to document the site(s) and stage(s) of pressure ulcers, as some pressure ulcers are HCCs depending on these factors. It is important for coding professionals to query providers if this information is missing, vague or conflicting. 

Read the full article in JustCoding for more examples of opportunities to improve on the coding and reporting of HCCs.

Bobbie Starkey, RHIT, CCS-P, is an outpatient consultant with 3M Health Information Systems.

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