Guest post: Risk grouping models for more than just HCCs

by Tammy Trombley, RHIT, CDIP, CCDS

Risk models group diagnoses according to ICD-10-CM diagnosis codes and categorize patients who share similar clinical characteristics and cost. Each risk model has a complex methodology where a particular diagnosis may trump another diagnosis, possibly affecting the final grouping. The models use coded data from medical records to influence payment and reimbursement. In addition, they all contribute to research and statistics for future healthcare planning.

For those who have been in the CDI industry for some time, remember what it was like to learn the MS-DRG payment system? Do you remember looking at the long list of MCCs and CCs and wondering how you were going to learn it all?

Then we learned about rules for exceptions. For example, acute myeloblastic leukemia as a secondary diagnosis for a principal diagnosis of pneumonia is a CC. However, if the patient is admitted for chemotherapy, then the acute myeloblastic leukemia serves differently in the MS-DRG methodology—it affects the MS-DRG, but not as a CC.

We practiced and practiced until we knew exactly which diagnoses would impact the MS-DRG and how.

Then, a few years down the road, maybe we learned about the APR-DRG payment model. We thought to ourselves, “What? Another DRG model to learn?!” We read articles, listened to webinars, searched the internet for references, attended conferences, and participated in learning modules to try to understand this new DRG system. And, just like the MS-DRG model, we practiced until we learned which diagnoses would impact severity of illness (SOI) and/or risk of mortality (ROM) for the APR-DRG.

Now, here we are with HCCs. In this model, Medicare uses beneficiaries’ characteristics (e.g., age, prior health conditions) and a risk-adjustment model—the CMS-HCC—to develop a measure of the patient’s expected relative risk for covered Medicare spending. The base payment for an enrollee is the base rate for the enrollee’s county of residence, multiplied by the enrollee’s risk measure, also known as the CMS-HCC weight. This payment structure, which is on an annual basis, uses demographics and a diagnosis-based medical profile captured during all clinician encounters—both inpatient and outpatient— to produce a health-based measure of future medical need.

It is important to realize that HCCs can significantly affect clinical documentation in the inpatient setting, too. Diagnoses that are HCCs are generally chronic conditions that will risk-adjust for various quality measures and in turn can impact not only publicly reported quality data, such as CMS’ Hospital Compare, but ultimately hospital reimbursement.

Editor’s note: This article has been adapted from the original published in HIM Briefings. Trombley is the CDI compliance manager for HCTec based in Tampa, Florida. She has 30 years’ experience in healthcare, including 21 years’ experience in inpatient and outpatient coding and nine years in CDI. Contact her at TTrombley@hctec.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.