June 19, 2012

HCCs and the “ICD-10 Revolution:” The transformation awaits for Medicare Parts C & D

By Michael G. Calahan, PA, MBA, AHIMA-Certified ICD-10-CM/PCS Trainer

By now everyone in the healthcare industry dealing with matters of coding is aware of the impending shift from ICD-9 to ICD-10 within the next few years (per recent accounts, this will occur not on Oct. 1, 2013 as initially scheduled, but instead on Oct. 1, 2014).

Effecting such an enormous change within the new time allowance, this quotation is quite apropos: “Don’t say you don’t have enough time. You have exactly the same number of hours per day that were given to Helen Keller, Pasteur, Michelangelo, Mother Teresa, Leonardo da Vinci, Thomas Jefferson and Albert Einstein.” (H. Jackson Brown Jr., Life’s Little Instruction Book).

While many might agree that Medicare is certainly a “piece of work,” not too many would classify it in the same category as a priceless Michelangelo. Nevertheless, there is overwhelming, demanding and even exhilarating work to be done in the newly extended timeframe.

Hierarchical Condition Categories (HCCs), the resource-reflective classification system developed for and used by Medicare Part C (Medicare Advantage) and Medicare Part D (Medicare Prescription Drugs), promises to be completely overhauled in the conversion from ICD-9-CM to ICD-10-CM. Chock-full of chronic diseases, debilitating and long-term conditions, and acute or developing illnesses and injuries secondary to pathologic processes, HCCs represent a slice of healthcare targeted for containment (and control, if possible).

HCCs often “front” the costliest medical issues the industry at large: diabetes and its complications; chronic kidney disease and renal complications; neoplasms; and respiratory, vascular and refractory dermatologic illnesses. Also included are the variety of drugs and biological and medicinal substances required to mitigate, alleviate and/or treat this legion of diseases and conditions.

The HCC classification system will be overhauled in the “ICD-10 revolution,” but this epic conversion actually might be invisible to the end user of diagnosis coding systems and HCC derivative systems. End users still will read and decipher medical record (MR) documentation, assign ICD-10-CM codes and input this data into the HCC grouper, with the output being the various clinical-model HCCs and RxHCCs (for prescription-based HCCs) ultimately used for CMS payment to the Medicare Advantage Plans (MAPs).

A couple of concerns loom on the horizon, however, in this massive changeover. Many of these concerns are IT-based. Mappers beware: at this time very specific ICD-9-CM codes map into the two major HCC models and RxHCCs. As we already know, with the conversion to ICD-10-CM, quality of data will improve, but quantity of data will increase. That means more information with which to manipulate, navigate and appropriate. That is, one single ICD-9-CM code might map to numerous ICD-10-CM codes. For example, 714.0 Rheumatoid arthritis currently maps into 20 ICD-10-CM codes, M05.40 through M05.471.

For the HCC coder, the devil is in the details. The range of data that now must be captured by the HCC coder (as documented by the provider) will include body part(s) affected by the rheumatoid arthropathy as well as laterality (for example, M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist). This, then, is the largest concern: the sheer number of individual ICD-9-CM codes that will convert into multiples of ICD-10-CM codes.

Another point of concern involves scenarios in which one ICD-9-CM code maps into the same ICD-10-CM code(s), but likewise groups are mapped into differing HCCs under the ICD-9-CM model. For instance, using the same example above for rheumatoid arthritis we have seen that code 714.0 maps to ICD-10-CM codes M05.40 through M05.471. Under Medicare Advantage, ICD-9-CM code 714.0 groups into HCC 38, HCC-ESRD model 40 and RxHCC 41 (using 2012 values). In the mapping of ICD-9-CM to ICD-10-CM, the “manifestation-underlying disease” ICD-9-CM code, 359.6 Symptomatic inflammatory myopathy in diseases classified elsewhere, also maps to the same ICD-10-CM code range: M05.40 through M05.471. However, ICD-9-CM code 359.6 currently groups into very different HCCs: HCC 71, HCC-ESRD model 75 and RxHCC 74.

Because these codes often are assigned together under ICD-9-CM but will represent the same ICD-10-CM code, obviously a little bit of IT magic will have to take place: CMS will have to coalesce the disparate HCCs into similar resource-reflective groups or develop a pairing type of grouper that will assign several HCCs based on historical ICD-9-CM data automatically, yet assign only one all-inclusive ICD-10-CM code.

 


 

Other possibilities for concern exist. There are scenarios in which two related ICD-9-CM codes map to the same ICD-10-CM code, but one ICD-9-CM code has a related HCC group and the other does not. For instance, ICD-10-CM code E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, maps to – among others – ICD-9-CM codes 362.02 and 362.07, which represent “proliferative diabetic retinopathy” and “diabetic macular edema,” respectively. However, only ICD-9-CM code 362.02 has an HCC group (119), an HCC-ESRD group (122) and an RxHCC group (111). ICD-9-CM code 362.07 currently only holds an HCC-ESRD group (18) and an RxHCC group (111), but does not have an HCC (regular model) group. Again, some IT magic must take place in terms of finessing the right ICD-9-CM codes – now mapped to certain ICD-10-CM codes – into the appropriate HCC groups.

Clearly, a fair amount of meticulous analysis and planning must take place. For IT personnel, a bumpy process is predicted. For CMS actuaries, certain islands located in the isolated South Pacific might look quite inviting right about now! But overall, the behind-the-scenes changes to HCCs following the ICD-10-CM conversion will not be readily apparent to HCC coders.

Their main concern will be aligning MR documentation to the new diagnoses afforded to them, with much richer detail and more elaborate code choices made available. And without question, CMS will take this opportunity to refine and perhaps redefine the current HCC groups based on the enormous potential posed by the ICD-10-CM diagnosis coding system, considering the richness of the data at hand.

Still, it will require a very thoughtful process. As Albert Einstein wrote, “The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.”

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.