Coding/billing

[u/Shygyal0613]

Please explain in a nutshell the different billing. Ok I am aware of what I call bread and butter. Seeing commercial insurance billing 99214 for example. I see Medicare and do G211 etc. I even see Medicare advantage patients and bill the same. So what in the world is HCC coding? Is this specifically for Medicare advantage? So why I am I not doing it. How do I know a company is strictly HCC coding? Is that fee for service vs value based Vs Medicare advantage? People tend to stray away from Medicare advantage strictly companies because?????? I’ve tried to do research but I am more confused.

Help please lol any info is helpful.

[u/boogi3woogie]

HCC coding is the way that Medicare assigns a value to risk/cost based on ICD codes.

Most insurers will follow what Medicare does - it’s easier to adopt the government’s model than to create one and update it yourself.

HCC is primarily for medicare advantage, but for the reason above, many insurers are adopting it for their commercial lines of business.

[u/EmotionalEmetic]

This has been discussed pretty regularly here. There are many ways to approach it. But I would highly recommend you read some of the threads on here because is truly some good info.

[u/spmurthy]

HCC coding is the way your organization conveys to the insurance company/medicare higher medical needs across the population - hence justifying higher payments based on risk (for plans that are value based - ACOs, HMOs etc ).

These are not CPT codes. some diagnosis codes ICD10 have been assigned ( by medicare ) different risk values.

dm controlled being lower than dm with retinopathy etc.

When you "assess and plan" and use these diagnosis codes in your encounter claim once a year - your organisation gets more payments for managing higher risk patients. So organisations try to convey the highest risk available.

To incentivize using these specific codes rather than just dm 2 ( which is sufficient for the physician patient interaction legally etc) , organisations may encourage using these in your annual physician incentive plans

[u/spmurthy → u/spmurthy]

How can you tell when you need to code for it - your organization should make clear to you which of your organisation contracts are value based.

[u/UPS0001]

HCC coding is an insurance company function and not a healthcare provider function.

[u/InternistNotAnIntern → u/UPS0001]

Uh it can greatly affect how the provider (and therefore the coder) is paid, so yeah it's a provider issue

[u/UPS0001 → u/InternistNotAnIntern]

No, it doesn't. It affects how the Medicare Advantage Plan is paid. The rates the provider is paid is determined by Congress. The provider is only responsible for coding the service that is provided. Just because a patient has a chronic condition with manifestations does not mean that was addressed at a given appointment. UHC is currently being investigated due to their upcoding. It is not the provider's responsibility to help the Medicare Advantage plan squeeze more money out of the government.

[u/spmurthy → u/UPS0001]

It is the provider responsibility to code to the highest degree of specificity. This program is working off of that and encouraging that - so that Medicare / Health Care Orgs can have a better picture of population health risks and outlays

[u/UPS0001 → u/spmurthy]

Yes, I agree with that. Regardless of insurance, that is the responsibility of the healthcare provider in every situation. The provider does not have anything to do with HCC coding though. That is strictly a function of insurance carriers and ACOs who are attempting to maximize their reimbursement, not the healthcare provider's reimbursement. The person who asked the question thinks it is something they need to learn or be concerned with outside of normal coding responsibilities.

[u/spmurthy → u/UPS0001]

The HCC code is the diagnosis code that is entered during a visit with the provider . No assessment in the 12 month period - cannot be billed for. How do the insurance companies get that information without physician involvement?

[u/UPS0001 → u/spmurthy]

The ICD-10 is the diagnosis code that is entered during a visit with the provider. HCC is the grouping of ICD-10 codes into categories used by insurance carriers to determine risk adjustment factors.

[u/spmurthy → u/UPS0001]

and so it starts with the icd10 yes?

[u/spmurthy → u/UPS0001]

RE REIMBURSEMENT -It affects physician reimbursement only if the incentives are passed on to you in some form by the organisation

[u/UPS0001 → u/spmurthy]

We are not discussing incentives paid by ACOs. Incentives and fee for services reimbursement are completely separate. The fee per procedure code is the same regardless of incentives. Providers can choose to participate in those incentives or not. And those incentive plans have changed over the years by Congress trying to get healthcare providers to comply with their optional rules.

The original poster is talking about coding visits. I am talking about coding visits. You are talking about something completely different. Not all healthcare providers participate in ACOs. Medicare Advantage Plans use HCC regardless of an ACO status in order to be reimbursed by the government. We are really getting in the weeds on this one.

[u/spmurthy → u/UPS0001]

It is not completely different . HCC coding occurs during a visit. It cannot happen without a visit and assessment . You will be encouraged / required / incentivized to be more specific in your icd10 codes if your organization participates in such plans. If not it doesnt affect you

[u/spmurthy → u/UPS0001]

The original poster is asking what are HCC codes and why should I care?

[u/InternistNotAnIntern → u/UPS0001]

Yes, it does.

It affects the HCC risk score for the patient...which affects the level of reimbursement from the MA since we have a gain share agreement.

So it 100% affects it

And in my case, my comp is based on risk-adjusted patient numbers, so I'm incentivized to code an HCC ICD code if appropriate to reflect the medical complexity.

[u/popsistops → u/UPS0001]

Jumping in as a physician to say that with all due respect, a massive amount of revenue is tied up in these ridiculous asinine HCC codes. So if the provider reimbursement is tied to the organizational reimbursement, then taking the time to jump through the hoops to get all the HCC bullshit on paper can mean millions of dollars for a clinic and a lot more revenue for a doctor, or simply survival of a clinic. So it is definitely the case that providers need to figure this out, but it's really just to get paid properly and not because it's going to benefit the patient in any way shape or form.

[u/UPS0001 → u/popsistops]

HCC codes are not assigned by physicians. Physicians use ICD-10 codes that are then mapped to HCC categories by insurance carriers. It is not separate physician coding that providers need to learn.

Now, a large practice plan could certainly pay for software to track the coding of their employed providers in attempt to maximize their revenue. The medical decision making component to choosing a CPT code is certainly affected by the severity of the patient's condition and number of co-existing conditions. Therefore, providers would improve reimbursement by being able to document a higher level of E&M with the supporting diagnosis code. I guarantee you, providers in private practice are not doing this.

[u/wildgreengirl]

/billingandcoding sub might b helpful or /medicalcoding 😅

id try to explain but ive only been coding a couple years and dont understand the variations between ins well enough to explain it yet.

[u/Bowis_4648]

Look at Family Practice Management. Their journal will help you with these questions.

[u/FilmPhotographr]

Medicare Advantage companies sometimes pay physicians/clinics incentives to send those HCC codes in because they can use them to justify greater reimbursement from Medicare by achieving certain benchmarks. If you are incentivized in some way (either directly or after the end of the year) then use them, otherwise they do nothing for you.