Medical Reimbursement Specialist

Medicare Risk Adjustment Data or Hierarchical Condition Categories (HCC)

What is a CMS-HCC Chart Review?

Some chart reviews are done to ensure that deserved reimbursement reaches your practice. The HCC Chart Review is one example.

Through a CMS-HCC chart review, the reviewer gleans out of your documentation those codes that may have been missed; or that may have been omitted from the encounter data submission; or that you may have been unaware merited a separate condition code. Submitting these by the deadline date guarantees that your payments in 2010 will reflect any deserved increase.

As part of the process, you will receive tips on how to improve your documentation so that you do not sacrifice reimbursement.

Your 2009 payments for patients in a Medicare Managed Care plan were based on the diagnoses submitted for those patients in 2008. Likewise, your 2010 payments will be based on what is submitted for 2009.

Our staff of certified coders are experienced in abstracting charts for this vital information. We have extensive experience in providing bilingual (Enlish/Spanish) guidance in this area.

How does CMS-HCC work?

Health status eventually replaces demographics factors as adjustment
Focal point is complete and accurate coding
Multivariate models sum “points” or weights for multiple factors to “score” an enrollee
Each enrollee gets a score based on which factors were present (e.g. Ten points for cancer plus 1 point for pneumonia plus five points for asthma yields 16 points)
2007 was the first year for reimbursement 100% based on this Risk Adjustment Data

What you can do today -

Provide education for all providers on appropriate documentation
Provide to all providers this handy Physician's Handout: HCC**
Train in-house coders to recognize HCCs while abstracting
On-going audits addressing HCC coding and documentation
Implement feedback mechanism for continous improvement
Get a baseline audit for your group and improve revenue
Access a complete list of HCCs directly from Medicare here: HCC.

** The HCC handout is also available with RAF or Category. Please call the office to request: 562-430-6847.