Specificity and accuracy are the keys to any successful Value-Based Care program. And clinical vignettes are a great way to learn.
Five years ago, the AAFP (American Academy of Family Physicians) published a crash course to educate family physicians on HCC coding. To this day, the clinical vignettes from this family physician HCC coding education course are still a great example of how and why family physicians need to diagnose specifically and code accurately in order to fully capture and treat the actual needs of their patients.
So if you are trying to educate family physicians on HCC coding, this Crash Course is a great place to start. As always, the M.E.A.T. criteria must be met in order to properly diagnose and accurately code any diagnosis.
What is the M.E.A.T Criteria in HCC coding?
- Monitor – signs, symptoms, disease progression, disease regression
- Evaluate – test results, medication effectiveness, response to treatment
- Assess – ordering tests, discussion, review records, counseling
- Treat – medications, therapies, other modalities
And here are the clinical vignettes presented in the AAFP’s HCC Coding Education Crash Course for Family Physicians:
Risk Adjustment Scores vs. Optimized Risk Adjustment Scores in Common Primary Care Encounters
Family Physician HCC Coding Example #1
Patient with DM II presents for routine follow-up. A1C 8.3. Also has stable COPD, oxygen dependent. O2 DME papers signed earlier this year.
| ICD-10 | Description | RAF | ICD-10 | Description | RAF | |
| J44.9 | COPD | 0.328 | J44.9 | COPD | 0.328 | |
| E11.9 | DM Unspec | 0.118 | Z99.81 | Oxygen Dep | ||
| J96.11 | Chronic Resp Failure w/ hypoxia | 0.318 | ||||
| E11.65 | DM w/ hyperglycemia | 0.318 | ||||
| Total risk= | 0.446 | Total optimized risk= | 0.964 |
Family Physician HCC Coding Example #2
68 y/o patient with hypertension and hyperlipidemia and BMI 37.2. Has been using CPAP for years.
| ICD-10 | Description | RAF | ICD-10 | Description | RAF | |
| I10 | Hypertension | I10 | Hypertension | |||
| E78.5 | Hyperlipidemia | E78.5 | Hyperlipidemia | |||
| G47.33 | Sleep Apnea | G47.33 | Sleep apnea | |||
| Z68.37 | BMI 37.0-37.9 | |||||
| E66.01 | Morbid Obesity | 0.273 | ||||
| Total risk= | 0.00 | Total optimized risk= | 0.273 |
Family Physician HCC Coding Example #3
Patient with diabetes and polyneuropathy. Right great toe amputated several years ago. He continues to smoke. Patient brought in multiple records from other providers. In addition to refill of meds, you counseled for 5 minutes regarding smoking cessation. You spend 35 minutes reviewing and summarizing the outside records and include that in the visit note.
| ICD-10 | Description | RAF | ICD-10 | Description | RAF | |
| E11.9 | DM Unspec | 0.118 | E11.41 | DM w/ polyneuropathy | 0.318 | |
| F17.219 | Nicotine dep/cig | F17.419 | Nicotine dep/cig | |||
| Z89.412 | Acquired loss L great toe | 0.588 | ||||
| Total risk= | 0.118 | Total optimized risk= | 0.906 |
Family Physician HCC Coding Example #4
Patient with HTN comes in for upper respiratory infection. Remote history of colon cancer and now has a chronic colostomy bag. DME orders signed earlier in the year.
| ICD-10 | Description | RAF | ICD-10 | Description | RAF | |
| J06.9 | Upper Respiratory Infection | J06.9 | Upper Respiratory Infection | |||
| I10 | Hypertension | I10 | Hypertension | |||
| Z93.3 | Colostomy status | 0.651 | ||||
| Total risk= | 0.00 | Total optimized risk= | 0.651 |
Family Physician HCC Coding Example #5
76 y/o presents with swelling of the left arm, redness, and pain. He takes warfarin for atrial fibrillation. He is also a liver transplant patient. Given IM ceftriaxone. PT/INR and CBC ordered.
| ICD-10 | Description | RAF | ICD-10 | Description | RAF | |
| L03.114 | Cellulitis of L upper ext | L03.114 | Cellulitis of L upper ext | |||
| I48.91 | Unspec afib | 0.295 | I48.2 | Chronic afib | 0.295 | |
| Z79.01 | Long term anticoag therapy | |||||
| Z97.4 | Liver transplant status | 0.891 | ||||
| Total risk= | 0.295 | Total optimized risk= | 1.186 |
Family Physician HCC Coding Example #6
Patient for follow-up of major depression, improving. New med started 6 weeks ago.
| ICD-10 | Description | RAF | ICD-10 | Description | RAF | |
| F32.9 |
Major depression, single, unspec
|
F32.1 | Major depression, single episode, moderate | 0.33 | ||
| Total risk= .000 | Total optimized risk= | 0.33 |
When educating doctors on HCC coding, be sure to avoid common HCC coding pitfalls by remembering these rules:
• Use documentation and coding to capture the severity of illness/risk of high cost
• Make sure that you capture the complexity of the patient
• Major issues need to be captured at least once a year (clock restarts Jan. 1)
To access the full AAFP HCC Coding Education for Family Physicians Crash Course, Click Here.
Need a real solution to train your family physicians on HCC coding for value-based care?
While this crash course is a great place to start, family physicians prefer to learn HCC coding and documentation for Risk Adjustment in the DoctusTech HCC coding education app. It is the only tool that consistently ranks #1 with both physicians and operators. Demo the app today.