Medicare’s MACRA and MIPS program has added resource use measures to every physician/provider of health care services in the United States that bill the Medicare Part B program. Resource use measures are part of the MIPS scorecard that will adjust (+ or -) future year Medicare fees paid to you and your practice. Resource Use Measures include Total Per Capita Cost, Medicare Spending Per Beneficiary, and CMS is testing new Episode of Care measures, most of which are explicit to patients with specific conditions (for example, Ischemic Stroke or Osteoporosis) and specific services (for example; Coronary Artery Bypass Graft, Pacemaker, Hip Replacement/Repair). Underlying these measures is a risk adjusting system called CMS-HCC (Hierarchical Condition Category). CMS-HCC’s are the only way to account for “my patients are sicker” in your MIPS scorecard.

HCC Tools provides an easy to use system to quickly find the appropriate and relevant ICD10’s within the CMS-HCC system. There are three ways to use this tools as listed below. For a demonstration, look at our How to Videos posted at www.adiratechnology.com.

1. Search the list of CMS-HCCs. Scroll through the list of CMS-HCCs for the most relevant category. Please note the risk weight listed for each HCC risk category. Any ICD10 linked to that HCC will add that risk weight to the CMS calculated patient risk score. Then click on an HCC category to see all linked ICD10’s (below) or if too many, add search criteria (separated by a space) to narrow your search results (like diabetes* retinopathy* detachment). Pick the ICD10 that best meets that patient’s specific condition and use it in your Medicare bill. (You can also click on any of the ICD10’s and add it to your favorites page in the tools).
2. Search all CMS-HCC linked diagnosis codes. You can keep adding to the key words in your search to get more and more specific. “Diabetes*” returns almost 500 ICD10s in the CMS-HCC program. Try “diabetes* eye*” then “diabetes* eye* detachment*”. Pick the ICD10 that best meets that patient’s specific condition. (You can also click on any of the ICD10’s and save it to your favorites page – more about this in C below).
3. Once you are registered and logged in, adiratechnology.com's HCC Tools will open to your favorites page. Use this page as your short cut to keep the most frequently used CMS-HCC ICD10s you need in your practice. Learn how to group the ICD10s in your Favorites page, by watching our instructional videos posted on the www.adiratechnology.com web site. You can group the CMS-HCC ICD10s in your favorites page into an order that best suits your needs. Your favorites page is dynamic, add to or delete ICD10s from it to keep it current.

CMS has used risk adjusting programs for over twenty years in their Medicare Advantage Program (and the predecessor Medicare Part C program) and the Medicare ACO programs. The principle is that while Medicare insurers millions of patients, some of which are “sicker” than others, across a large population there are likely as many less-sick as there are more-sick patients. Once the Medicare population is split into smaller segments for health plans and ACO’s with a few thousand patients, there needs to be a way to account for differences in patient acuity.

CMS-HCC (Hierarchical Condition Categories) utilizes a subset of ICD10 diagnosis codes (approximately 8,000 of the 70,000 ICD10 diagnosis codes) to identify patients falling into one of 79 CMS-HCC risk categories. The risk categories in most cases are additive, where patients can have multiple risk factors tied to different categories and the patient risk score is the sum of the risk weights of each relevant HCC risk category in addition to relevant demographic factors. Physicians and other providers need to know how to find and use the appropriate ICD10 diagnosis codes within the CMS-HCC system to be sure they are getting credit for their patients’ illnesses. Proper coding on bills to Medicare at each patient encounter is vital, as is coding all relevant CMS-HCC diagnosis codes during a CMS annual wellness visit (billing service codes G0438, G0439). CMS-HCC does not remember patient conditions and codes from year to year. Each year all relevant CMS-HCC ICD10 diagnosis codes need to be reported to CMS through bills sent to Medicare.