ICD-10 and the HCC Impact

When the healthcare system goes through the biggest overhaul in its history, Hierarchal Condition Categories (HCCs), will be

When the healthcare system goes through the biggest overhaul in its history, Hierarchal Condition Categories (HCCs), will be part of the transition. The Risk Adjustment Industry is already feeling some frustration, as the government has stopped issuing updates for HCC categories. Payers are naturally concerned as there are more than 1,000 HCC ICD-9 codes that do not have a one to one translation when crosswalked to ICD-10, which means Plans will need to establish a methodology to determine when to use multiple codes and when to split codes for HCCs. and being forced to wait on government guidance for updates until or shortly before October 2014, makes planning and preparation a challenge for them.

Key Analytics For Successful HCC Capture

 Collect Medicare Claims And Encounter Data
 Processing/ Submission To CMS
 Identify High-Risk Members With Chronic Conditions
 Provide Early Intervention To Ensure Quality Clinical Outcomes
 Continuity of Member Assessment form Plan Members
 Retrospective/ Prospective Reviews, including Chart Audits/ Hospital Abstracts
 Financial Review/Reconciliation
 Web-Based Reporting/Analytics
 Health Status Re-Determined Each Year/Assessed/Treated/Documented Annually
 Diagnosis Reported Through Claims/Encounter Data
 Quarterly Review of Member RAF Scores below 1.00 and unusually high RAF Scores or “Jumps” In RAF Scores
 Document And Code All Conditions That Are Evaluated At Each Visit

It’s All About The RAF (Risk Adjustment Factor - RAF score simply identifies patient health status)

CMS suggests that an average senior who is generally healthy should have an average RAF score of 1.00:

 RAF scores above 1.00, suggest a patient with chronic conditions
 Lower RAF score indicates a healthier population - RAF scores below 1.00, suggest a healthy patient

A Lower RAF Score May Also Indicate The Following Issues:

 It may be falsely indicating a healthier population because of a lack of adequate chart documentation or incomplete and/or inaccurate ICD-9 coding
 Patients have not been seen
 It may be indicative of insufficient claims data submission

Coder’s ICD 10 Risk Adjustment Hit List for Providers

The following list is comprised of what I consider to be “mission critical” items that coders must ensure that providers are documenting and reporting consistently now and when we transition to ICD 10., in order to accurately depict a members Health Risk Profile.

 Is The Condition Acute Or Chronic
 Is This Diagnosis A Manifestation Of A Disease
 Is The Diagnosis Really A Symptom Of An Underlying Disease
 Do Findings From Lab, Imaging, Or Pathology Correlate To A Chronic Condition
 When A Patient’s Medication Is Increased, Do You Document That It Was Because Of Worsening Symptoms Of A Chronic Condition
 Is It Sepsis/Septicemia/Bacteremia
 Is The History Of Myocardial Infarction With Symptoms Or Really Chronic Ischemic Heart Disease
 Is Your Treatment Plan To “See A Nutritionist” In Any Way Related To A Patient Having Uncontrolled Diabetes
o Diabetes - Type 1 Or Type 2 -
o Primary /Or Secondary
o Controlled/ Or Uncontrolled
o Is The Patient Insulin Dependent
o Manifestations - Such As Diabetic Retinopathy
 Is Documentation Legible

Sampling of Common HCC codes and how they will be coded in ICD 10:

ICD-9-CM - Code/Title
284.89: Other specified aplastic anemias
ICD-10-CM - Code/Title
D61.1: Drug-induced aplastic anemia
Key Differences - Specificity regarding cause

ICD-9-CM - Code/Title
250.51: Diabetes with ophthalmic manifestations, type 1 not stated as uncontrolled; plus
362.05: Moderate non-proliferative diabetic retinopathy; plus
362.07: Diabetic macular edema
ICD-10-CM - Code/Title
E10.331: Type 1 diabetes with moderate non-proliferative diabetic retinopathy with macular edema
Key Differences - Combination codes for diabetes and associated complications; identification of controlled vs. uncontrolled

ICD-9-CM - Code/Title
174.2: Malignant neoplasm of female breast, upper-inner quadrant
ICD-10-CM - Code/Title
C50.211: Malignant neoplasm of upper- inner quadrant of right female breast
Key Differences - Laterality

Final Thoughts

Having those challenges from the government, is pushing Plans to assure providers that they are working towards providing as seamless a process as possible, as they transition to ICD-10 to ensure that there will be minimal impact on reimbursement. Professional Coders and Billers must also ensure that they too are working with their respective professional affiliations to stay up to date on ICD 10 news and are building a working ICD 10 knowledge base.
For more ICD 10 information from the AAPC or AHIMA, please click on the following links:



Happy Coding!


About Holly Cassano

Over 16 years in the healthcare industry - CEO, CPC ACCUCODE Consulting, LLC June 2012 – Present Multi-faceted Coding Consulting Company - Risk Adjustment Coding/Auditing, Multispecialties - Coding/Auditing all aspects. Assisting Coders with remote and local coding projects. She is dedicated to helping Certified Coding and Billing professionals with all questions, assist future Coding and Billing professionals gain knowledge and direct them towards the appropriate training.