HCCs: An awareness perspective

April 6, 2022 / By Richard Wetherbee

The idea that, at some point in each of our lives, we may become acutely ill, eventually leading to the development of a chronic medical condition is a very real possibility.

The truth is that any acute or chronic medical event may prompt a visit to a primary care provider (PCP). This visit could be for an annual wellness checkup or an acute assessment of an evolving or unexpected illness. 

One category of illness I want to briefly touch upon is what lies within the spectrum of a chronic disease interaction. Specifically, how an awareness of a face-to-face visit with your doctor requires additional knowledge and understanding of key elements within the clinical documentation requirements of hierarchical condition categories (HCCs).

HCCs are used by the Centers for Medicare & Medicaid Services (CMS) to determine risk adjustment factors for Medicare Advantage Organizations (MAO) programs and payments. As defined by the CMS, risk adjustment predicts the future health care expenditures of individuals based on disease burden, diagnoses and demographics. Risk adjustment modifies payments to all insurers based on an expectation of what the patient’s care will cost. So why is it so important for our providers to understand this methodology?

Well, for example, a disease interaction may manifest itself as a certain combination of diseases such as diabetes and congestive heart failure (CHF). This disease interaction between diabetes and CHF has a higher expected cost of care than someone who may only have diabetes or a patient who has only CHF. Proportionately, disease interactions result in higher risk scores for these patients when these types of disease parings are present, diagnosed and then precisely documented by a primary care provider.

Now, let’s take a minute to think about the number of patients entering a U.S. PCP office in 2022 to see their respective provider on any given day and over a calendar year. That’s a lot of visits and a tremendous amount of required documentation for our PCP, right?

Now, ask yourself how is it that our excellent PCPs can keep up with this patient demand and assure continuity of care in today’s challenging health care continuum, adhere to process improvement and flow initiatives, remain focused on quality measures, expected outcomes and seemingly navigate the continual and evolving variety of regulatory, societal and logistic challenges placed on their specific PCP practice?

Let’s pause and take a quick look through the lens of how a patient may see his experience as he enters his primary care physician’s office.

Mike is a 66-year old white male with type II diabetes mellitus (DM) and congestive heart failure (CHF). Mike just arrived at his PCP’s office for an appointment related to a very mild increase of shortness of breath upon exertion over the last two to three weeks. Mike appears in no real distress, so he checks in with registration and is ready to see his PCP.

Mike follows a staff member toward the exam room. He stops off at the scale and is asked to step on for a weight check. Then, Mike enters a previously selected exam room. He goes through a series of questions and has a set of vital signs done; all of which are entered into his medical record by a competent PCP clinical staff member.

Mike waits anxiously for his PCP who promptly arrives. Now, his PCP initiates a series of face-to-face questions related to his reason for visit, such as reviewing his history of present illness, monitor how he’s feeling today, a review of systems, discuss any new symptoms, a review of vital signs, his weight, BMI, lab results, a discussion on nutrition, his medication compliance, dosage and administration, to determine what Mike’s current overall physical state is based on these findings.

This assessment continues for several minutes and finally a treatment plan is discussed. Mike now has a very good understanding of the next steps toward his continued treatment plan associated with his DM and CHF.

Wait! What happens now and what is documented by Mike’s PCP within his medical record based on his recent visit? His DM and CHF seem under control and his medications for CHF have been re-adjusted today so, what should Mike’s PCP consider when documenting his chronic conditions with this disease interaction?

These are important items to ponder. For PCP’s, understanding the origin of a patient risk level will help make important care management decisions, such as providing greater access and resources to patients in higher risk levels. In my next blog, I will provide a snapshot discussing specific documentation criteria and the importance of understanding a patient’s risk level and how this impacts the patient experience and the PCP face-to-face interaction.

Richard Wetherbee is a clinical performance improvement specialist 3M Health Information Systems.