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HCCs: Ambulatory vs Acute Care Setting

So you thought hierarchical condition categories (HCCs) only mattered in the outpatient arena, but this is a common misconception!  These diagnoses have an impact on various quality and mortality metrics within the acute care setting.  There are also several diagnoses which occur mostly in hospitals that can affect RAF scores and thus future reimbursement. 

One diagnosis almost never seen in the ambulatory space is an acute stroke.  This diagnosis, unlike that of a myocardial infarction (MI), is not carried into the office setting and thus is only captured in the hospital.  Acute stroke falls into HCC 100 which, using disease coefficients for 2020, has a weight of 0.23.  HCC 100 is part of a hierarchy thus a diagnosis of nontraumatic intracranial hemorrhage, I61.x will lead to HCC 99 with a disease coefficient of 0.23.  Consequently, documenting hemorrhagic transformation of a cerebral infarct changes the HCC but also results in a MCC for hospital reimbursement.  This emphasizes the importance of complete and accurate documentation since the disease coefficients for HCC 99 and 100 are the same in this example using the most common category of community, non-dual aged population. However, this is not true for some of the other categories.  

Other Conditions Not Common in the Ambulatory Setting 

Other conditions not commonly treated in the office setting are those that fall into HCC 17, diabetes with acute complications.  These diseases, such as diabetes with ketoacidosis E.11.10 or diabetes with hyperosmolarity E11.00, will fall into this grouping and will override HCC 18, diabetes with chronic conditions and HCC 19, diabetes without complications. 

Infections are very common in the ambulatory setting but sepsis A41.9 is not.  The diagnosis of sepsis can often be challenging with multiple definitions particularly by payers.  However, this is important to document as it affects many CMS metrics (e.g., sepsis if POA will exclude the patient from the pneumonia readmission cohort) and carries significant HCC weight of 0.352 falling into HCC 2.  Other conditions such as hypovolemic shock R57.1 and SIRS R65.10 will also fall into this HCC.  

What about Acute MI? 

As mentioned earlier, acute myocardial infarction can be carried into the office setting within the first 28 days of its occurrence and it carries an HCC weight of 0.195 within HCC 86.  This HCC is within a hierarchy of HCC 86, 87 and 88 with HCC 86 being the highest weighted.  This does not mean we shouldn’t capture some of the complications of the MI while the patient is hospitalized as these are often risk adjusters for various CMS metrics.  We also want to document cardiogenic shock R57.0 if present as that falls into HCC 84 which is not part of the hierarchy that includes the acute MI.  Acute respiratory failure J96.0 is also within the same HCC 84.  There is a hierarchy involving this HCC and respiratory arrest R09.2 falls into HCC 83 which overrides HCC 84.  The disease coefficient for HCC 83 is 0.354. 

The complication of cardiogenic shock R57.0 or acute respiratory failure J96.0 is separate from the MI hierarchy and is in HCC 84 which would be an additive HCC to the MI.  If a respiratory arrest occurs R09.7, this would be in HCC 83 which overrides HCC 84. 

Any other important conditions to note? 

Lastly, other things to look for and appropriately document include 1) malnutrition, which can either be severe or non-severe, and will fall into HCC 21 and 2) alcoholism with withdrawal delirium F10.231 is a higher weighted HCC than alcoholism in many of the demographic categories. 

The importance of complete and accurate medical documentation cannot be over emphasized in the capture of HCCs and other conditions because they often affect quality and other metrics.  As we promote here at Enjoin: Documentation determines destiny! 

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