Skip to content
1-866-359-4458 Log In
Get Started

How to Capture HCC Coding Pitfalls, Three APP Measures, and Joining an ACO

This week, Dr. Dan Mingle offers some insight into how to capture HCC coding pitfalls, shares context about the number of measures in the APM Performance Pathway (APP), and answers more questions about joining an ACO.

Click play to listen to this episode right now:

Question One: Capture HCC Coding Pitfalls

Lori asks: “Is there any technology, or even lists, to capture the top HCC risks?”
  • A quick explanation of HCC codes may be helpful here: multivariate statistical analysis of Medicare claims has shown a correlation between specific diagnosis codes (or combinations of diagnosis codes) with higher healthcare costs. It stands to reason that patients with more complicated health situations will cost more over time than patients with less complex conditions.
    • Medicare assigns scores to these codes/code combinations to adjust charges and payment profiles for complexity. The theory is that practices taking care of more complex patients have higher costs and consume more of the annual Medicare budget.
    • CMS introduced this system to adjust payments in Medicare Advantage plans starting in 2004. In recent years, it’s become apparent that cost and quality measures require risk standardization as well, so Medicare has also applied the system to its value-based payment programs.
    • Medicare updates its analysis of codes and risks for the model annually.
    • Over 10,500 ICD-10 codes are mapped to 86 HCC codes, and each HCC code receives a numeric cost score.
    • Some HCC codes are additive, and some are exclusive. This hierarchical staging of codes is why the system is called Hierarchical Conditions Codes (HCC).
    • CMS publishes the mapping logic of ICD-10 codes to HCC codes in a spreadsheet format inside “model software, ” meaning it can be a little difficult for the casual reader to understand the annual updates.
    • For providers, the practical implication of this annual cycle is that HCC-scored ICD-10 codes must be used by the provider in a service year for that code to be applied to the patient. It’s not enough to diagnose a condition once and have that diagnosis and corresponding HCC code apply to the patient year-over-year.
  • Unfortunately, it’s tough to find articles, presentations, and rules describing the entire system. For any comprehensive analysis, you’ll likely require vendor assistance.
  • Dr. Mingle mentions that he’s done some coding and analysis of these systems in the past and found a missing code analysis and near-miss analysis helpful when trying to capture HCC coding pitfalls.
    • To perform a missing code analysis:
      • Search for HCC-mapped ICD-10 codes made for each patient in previous years that have not been used this year.
      • In Dr. Mingle’s experience, he’s found a high correlation between HCC-accurate EHR problem lists and the annual use of HCC codes. In other words, if it’s in the problem list mapped to the correct HCC ICD-10 code, it’s more often than not included in a diagnosis sometime that year. If the diagnosis didn’t make it to the problem list, it’s unlikely to be recoded.
      • It’s good to do this analysis to compare this year to last year in your practice, group, or organization. It’s even better to perform this analysis comparing multiple years.
      • This process can be even more valuable if you work with a vendor with access to insurer-sourced claims like Medicare CCLF files. With this capability, you can track patients across all providers for multiple years.
      • Finally, combining this process with an update and clean-up of EHR problem lists can help you confirm that codes will continue to be used year-over-year.
  • To perform a near-miss analysis:
    • Search for codes that are not HCC-mapped but are related to HCC-mapped codes.
    • Combine this search with a process that checks eligibility for the HCC-mapped code and update the problem list as indicated.

Question Two: Three APP Measures

Gretchen asks: “In the process of sunsetting the Web Interface for MSSP ACOs, Medicare has cut the number of measures from ten in the Web Interface to three by MIPS CQMs or eCQMs in the APP. Why the reduction in the number of required measures?”
  • There are likely three reasons for the reduction in the number of required measures:
    • The existential requirement of political expediency—Medicare won’t do well if they make everyone unhappy. Trading one painful policy to relieve some barriers can be considered a nod to political expediency.
    • CMS is committed to the “meaningful measures initiative” to move toward meaningful measures instead of measures for the sake of measurement.
    • CMS is also committed to reducing the burden of measurement for providers.
  • In the case of the APM Performance Pathway (APP), focusing on the three chosen measures fulfills all three requirements. Reduction in the total number of measures is politically expedient, gives a nod to the goal of reducing burden, and the three chosen measures fit the meaningful measures initiative well.

Question Three: MIPS and ACO Quality Submissions

Karen asks: “What are the implications to a practice when there are some providers reporting quality with the ACO and others that are MIPS participants?”
  • Every APM has some reporting requirements, whether those requirements are unique to the specific APM or piggyback on some other reporting program like MIPS.
  • Those who are qualified participants in your ACO will not make a MIPS submission. They’ll submit with the ACO’s quality submission.
  • For MIPS providers, the requirements are dependent on how you report. Only those needing a MIPS submission will submit MIPS if you report as individuals. But, with the enormous advantages of group submissions over individual submissions, it’s more likely your MIPS participants will submit as a group.
    • According to CMS, group submissions should include all patients, all insurers, and all providers in the group.

Question Four: EMR Certification and APMs

Karen asks: “Is it a requirement that the EMR be certified to participate in an APM? Would we have to implement a patient portal?”
  • A certified EHR is a requirement for all Alternative Payment Models (APMs).
    • We know from Karen’s earlier questions that their organization is joining an MSSP ACO. The current requirement for MSSPs is that 75% of the participating providers are on a certified EHR.
    • So, a certified EHR isn’t exactly a requirement. The 25% allowance can cover practices that don’t have an EHR or are on an uncertified EHR.
  • The patient portal issue is a little bit different.
  • You’re not required to have a patient portal if you’re a qualified participant in an advanced APM (although it’s still a great idea).
  • If you’re in a MIPS APM, your score for the Promoting Interoperability performance category will contribute to your global MIPS score. In this case, the patient portal counts for 40 points out of your possible 100 points for Promoting Interoperability.
    • There are 10 bonus points available to offset some of the 40 point loss you’ll encounter without a patient portal.
    • While not having a patient portal will impact your Promoting Interoperability score, you can still make it up with your other scores for Quality, Cost, and Improvement Activities to attain a high overall MIPS score.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

Want to learn more about HCC Coding?

As we transition into value-based care, understanding HCC coding has become essential for organizations to succeed in new payment models. Our blog post, "HCC Coding & Value-Based Care: Key to Success for Primary Care First", contains helpful information on HCC coding and how it can impact performance in innovative programs like Primary Care First.

Learn More
Get Helpful News & Resources
  • This field is for validation purposes and should be left unchanged.