HCC coding compliance Q&A

Norwood hosted a webinar on Nov. 12, Navigating Regulatory Waters in Risk Adjustment: The OIG, False Claims Act, and HCC Findings.” During the show we got several excellent comments in the Q&A chat. Below is an excerpted and lightly edited transcription. You can view an on-demand recording of the full program here: https://my.demio.com/ref/o0WT9l8jMiof0v8L 

Question: We have a problem with the limitation of only allowing submission of 12 diagnosis codes per claim, when providers document as many as 20. Any suggestions for remediations here?

Answer: Depending on the payer, you could file another claim for that same date of service with CPT 99499 and have an additional 12 diagnoses. If there are two service codes (problem focus and annual wellness visit for example), this would allow you to split the claim and report 24 diagnoses. Your payer would love to give you solutions to this.

Question: I have found during audits that the word “stroke” is sitting on the problem list, and after the patient is discharged from inpatient status for said “stroke” and visits their PCP in an outpatient setting, the PCP just clicks “stroke” off of the problem list—not knowing that the code is for an “acute stroke”. Do you have any suggestions for this scenario?

Answer: Problem lists are a big focus and problem; the best answer is that the physicians should be changing it to either a “history of” code or applying the codes for any sequelae of the stroke.

Question: What is the best way to help automate a process for code auditing to help with HCC compliance?

Answer: Our organization built a work queue in Epic to pull in outpatient clinic accounts with acute MI, acute CVA, DVT/PE, and cancer diagnoses. These cases are reviewed by the CRC credentialed coder prior to being billed. He or she looks at documentation, problem list updates, and potential query opportunities, as well as noting future education topics for providers. We have had great success with correcting coding compliance issues and wonderful provider engagement with this solution! You might also want to target high confidence suspect conditions using a special “high fail” retro review, focusing on the high risk diagnoses mentioned in the presentation as being flagged or audit by the OIG (acute stroke without a corresponding inpatient visit, etc).