HCCs and physicians

July 31st, 2017 / By L. Gordon Moore, MD

As a physician, I am responsible for coding certain diagnoses that will trigger certain payment and risk adjustment. Risk adjustment scores are important in terms of quality measures and they affect reimbursement. I’d prefer not to have to learn all the details and nuances of different languages like Hierarchical Condition Categories (HCCs). Technology should be able to do this work for me. I’m interested in tools that can show gaps in patient diagnosing. This would enable me to more fully focus on my patient without the burden of trying to remember and code all the condition details. Technology should provide efficient and accurate data without me having to dig and take time away from my patients.

HCC requirements are the same as coding requirements from CMS. Per CMS rules, each patient starts January 1 with a blank slate – i.e. no carry-over of diagnosis codes. Sometime during the calendar year, the goal is to address all of the person’s chronic conditions, document, then submit claims.  If my health IT gives me data on “missing diagnoses” from data that do not include claims submitted by other providers, I might be wasting the patient’s and my time if I were to bring them in for a visit to address conditions already covered by others.  If the technology enabled a broader look at data surrounding chronic conditions, I would be more accurate and time efficient.

Many EMR companies are working in this space, to enhance HCC capture and perfect the data. In the ideal setting, technology provides a deeper understanding by capturing the widest possible data set to reduce the “false positive” alerts (an alert to a physician to do something that has already been done.) This requires the ability to sift through very large datasets quickly and apply methodologies translating diagnoses into HCCs, and a rules engine that knows what to do with the information. This should result in more useful information and less unnecessary work for busy clinicians.

Natural language processing and the capacity to understand concepts across the myriad of nomenclatures in health care (ICD-10, ICD-9, CPT4, SNOMED, HCC, LOINC, and so on) would be a good start to a more intelligent approach.

Let’s say I’m the medical director of health system with some hospitals, outpatient clinics, and a network of affiliated practices and groups. The hospital and clinics are on a single EMR but the affiliated practices are on a hodge-podge of ambulatory EMRs and a true enterprise data warehouse is far in the future. I have several value-based contracts with Medicare Advantage plans and commercial insurers, and an MSSP program. Every month I send each of the PCPs a list of their patients who continue to have un-diagnosed chronic conditions. The PCPs are raising increasing concerns regarding the quality of the lists.  Some point out that our facility/outpatient data misses the instances when the PCPs have already seen the patient and submitted claims while others point out that some of the “missing conditions” don’t actually contribute to HCCs. We perform some chart audits and often find many of the “missing” conditions are addressed in the doctors’ notes but not always showing up in the claims.

Here are solutions that intelligent technology can bring to these problems:

  • A longitudinal patient record: Since HCC reporting requirements are based on claims, the broadest data set would be adjudicated claims from the health plan.  This would show me all of the codes submitted by any provider seeing the patients in our contracts.
  • Advanced natural language processing can find instances of diagnoses documented in a note but not showing up in claims and provide a health information management department an opportunity to query the doctor about a missing diagnosis code.
  • An intelligent rules engine that can minimize the busy work of a health information management department by identifying the right information and providing a seamless work flow across multiple spheres of work.
  • A minimally invasive alerting engine providing the essential information within the context of daily work without over-burdening doctors and nurses in the front lines of healthcare delivery.

Clinician’s days are filled with friction and frustration, burdened by work that technology should be managing for them. We are trying to minimize these frustrations by tapping into smart, advanced technology. EMRs were originally made to make these tasks so much easier. Unfortunately, I think it had the opposite effect in some ways. Many of my colleagues are so tired of the electronic work we now have, they question if they should’ve chosen another field to work in.

More intelligent technology could enhance our work and minimize our daily frustrations by:

  • Providing a broader view the patient’s history across multiple providers
  • Offering details about chronic conditions
  • Automatically identifying gaps and deficiencies in physician documentation
  • Provide essential information in a way that is more supportive than invasive and within the daily workflow of physicians

L. Gordon Moore, MD, is senior medical director for Populations and Payment Solutions at 3M Health Information Systems.


More about HCCs: Hierarchical condition categories: Get documentation and coding right