Rheumatology coding must reflect comorbidities patient care complexity

SAN DIEGO — Rheumatologists consider chronic comorbidities and their effect when treating patients and this must be referenced and documented in claims to impact the CMS Hierarchical Condition Category and influence “CMS tolerance of cost,” said an expert here.

Introduced in 2004, CMS created the Hierarchical Condition Category system which assigns risk “which translates directly to expected cost of care in patients,” said Gloria Johnston, MBA, RN, RHIT, Chief Health Information Officer of HealthAdvanta, here at the United Rheumatology National Meeting.

“The more complex your patients are, the higher tolerance CMS will have for the cost of care for those patients,” she said.

“HCCs come into play if you have patients attributed to your practice. You want to ensure that those patients are described appropriately based upon their whole person so if they have multiple comorbidities that the CMS allows for a higher tolerance of cost” and they use claims to do so, she said.

HCC risk score reflects the overall health status of a patient and its influence on clinical factors as well as demographic factors and are derived from ICD codes submitted on Medicare claims, Johnston said. Diagnoses from every provider that sees an individual patient is a contributor in the overall HCC risk score.

“So how do you play defense in terms of this cost attribution?” Johnston asked. “First and foremost, you want to make sure that every Medicare patient … has a PCP who manages their holistic care.”

Also, “make sure a patient’s complexity is expressed on the claim form so you can align your beneficiary risk with the cost you are held accountable for.”

Risk adjustment is not a concept exclusive to Medicare. Accountable care organizations, Medicaid, Medicare Advantage plans and private payers use beneficiary risk, she said. The transition from fee-for-service to population management the “risk adjustment scenario becomes more important.”

Johnston said the top chronic conditions that influence beneficiary risk are chronic heart failure, vascular disease, ischemic or unspecified stroke, ischemic heart disease, specified heart arrhythmia, angina, morbid obesity, rheumatoid arthritis, inflammatory connective tissue disease, cancer, diabetes, chronic obstructive pulmonary disease and major depressive and bipolar disorders.

Johnston said it is important to note that HCC are “wiped clean each January.”

She suggested capturing comorbidities for all new patients and at least once a year for established patients. She said the first appointment of a calendar year is a good idea and also she highly recommended being as specific as possible, and warned of “copy and paste.”

Johnston gave examples that would satisfy the CMS Assessment and Plan section such as:

Hypertension: BP 138/82 today. Well controlled on Atenolol 100 mg daily;
Morbid obesity: BMI 41.2 today. Referred to PCP for BMI management; or
Chronic atrial fibrillation: Asymptomatic today, on Warfarin. Managed by cardiologist.

“Putting something in someone’s past medical history or putting it on the problem list is not the same as actively considering that information.”

If you are thinking about a comorbidity and considering it, then it is appropriate to document it, she said. – Joan-Marie Stiglich, ELS

Reference:
Johnston G. HCC coding and the importance of documenting comorbidities. Presented at: United Rheumatology National Meeting. April 20-21, 2018; San Diego.

Disclosure: Johnston is an employee of HealthAdvanta.