Q&A: 2020 CMS-HCCs model

On October 21, 2020, the ACDIS Podcast: Talking CDI hosted Jennifer Eaton, RN, MSN, CCDS, executive director of CDI services and education at Enjoin based in Eads, Tennessee for “2020 CMS-HCC Model.” After the show, Eaton answered the following questions from listeners.

ACDIS: What is the best way to word a prospective query to be compliant?

Eaton: Queries first and foremost must be compliant. That includes being nonleading and clinically supported with viable response options if using a multiple-choice format. For example:

The physician documentation notes the patient has a body mass index of 42 and the treatment plan notes “dietary modifications reviewed and increased activity/exercise encouraged.” A compliant query would pull those facts forward and then ask the physician:

“Based on the assessment of the patient, can the body habitus be specified as:

• Morbid Obesity
• Obesity
• Other_______
• Unable to clinically determine”

ACDIS: How do telehealth claims factor into CMS risk adjustment eligibility—particularly those audio-only calls that have been allowable during the COVID-19 pandemic?

Eaton: Per a CMS memo dated 4/10/2020, titled “Applicability of diagnoses from telehealth services for risk adjustment:”

“Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.”

ACDIS: HCCs are tied to payment to Medicare Advantage plans for their capitation rate. Why should hospitals expend resources to get insurers more money/profit when it does not benefit the hospital?

Eaton: Correct documentation, coding, and capture of HCCs positively affects a host of value-based reimbursement initiatives and helps risk-adjust patients included in CMS’ 30-day readmissions/mortalities/complications (therefore affecting hospital penalties related to poor performance in these programs). HCCs also influence shared risk agreements with accountable care organizations that are owned by health systems. So, while it may not seem immediately beneficial there are a host of downstream reasons to be watching documentation improvement efforts related to HCCs.

ACDIS: Is CMS moving away from a blended model using encounter data and risk-adjustment factor (RAF) models, looking to use only encounter data to calculate risk score? Does this mean they will no longer use demographic data in HCC calculations? 

Eaton: Demographic data will continue to be used. As part of the phase-in plan for 2022, CMS is also evaluating the impact of other factors on risk adjustment. These include additional diagnoses codes related to mental health and substance use as well as severity of chronic kidney disease. Its also taking into consideration the total number of diseases or conditions as well as adjustments for dual eligible beneficiaries.

ACDIS: I recently talked to orthopedists about HCC capture and their concern was that they do not necessarily monitor, evaluate, assess, or treat these conditions during an acute care admission for hip and knee replacement. Is it appropriate for them to capture HCC?

Eaton: You are right on target with considering MEAT—monitored, evaluated, assessed, treated—criteria when assessing HCC compliance. Did the provider refer to the home medications list and either continue medications or hold for some reason during the inpatient stay? Were any chronic conditions taken into consideration when planning the patients inpatient care (medications, labs, monitoring)? Also note that any acceptable provider type is required to capture HCCs.