FAQ on Diabetic Hierarchical Condition Categories (HCC) Coding 

The hierarchical condition categories, commonly known as HCCs, are vital in medical billing and coding. The knowledge of HCCs is a must now for every medical practice, especially in diabetes, as healthcare organizations have to provide value-based patient care. Though HCCs is a concept that has been introduced previously, it was not at the forefront earlier. But with patient-centric care being the norm of the day, the knowledge of HCCs will enable the practices to reduce the risk of not getting paid or facing a prolonged reimbursement process. This article will discuss some of the basic FAQs on diabetic hierarchical condition categories (HCC) coding. 

1. What are HCCs In Diabetes?

Hierarchical condition categories (HCCs) coding is a set of codes in the medical practice that also have specific codes for diabetes associated with certain clinical diagnoses. The Centres of Medicare and Medicaid Services (CMS) have been using HCCs since 2004. They have used it to identify individuals who suffer from chronic, acute, or severe conditions under the risk-adjustment model. HCC codes, when used for any chronic or acute diabetic or other patients, allow Medicare to project the future risk and annual care cost of the patient.

2. Who can use Diabetic HCCs codes?

Any patient insured under Medicare Advantage (MA) plans, specific Affordable Care Act (ACT) and Accountable Care Organizations (ACOs), and a few other plans can be categorized under HCCs if they are suffering from acute, chronic, or severe diabetic issues. The clinician will use the HCC codes for the patient’s medical record with the supporting documents mandated by the CMS and put forth to the insurance company.

3. What are the diabetes diagnosis hierarchical condition categories (HCCs)?

For the diabetes diagnosis, there are three HCC coding, they are:

  • HCC 17 Diabetes with Acute Complications
  • HCC 18 Diabetes with Chronic Complications
  • HCC 19 Diabetes without Complication

All these three HCCs coding begins with the categories of ICD-10-CM. They are as follows:

  • E08 – There is an underlying condition causing diabetes mellitus
  • E09 – Diabetes mellitus caused by inducing some chemical or drug
  • E10 – Diabetes mellitus Type 1
  • E11 – Diabetes mellitus Type 2
  • E13 – Diabetes mellitus of other specifications

These categories are further segmented into different subcategories based on their chronic and acute complications and without complications.

4. How to understand the diabetes hierarchy conditions?

In diabetes HCC coding, there is a hierarchy in which HCC17 is the highest rank while HCC19 is the lowest. When the risk score is calculated, the highest ranking in the diabetes HCC diagnosis is used within the hierarchy for the patient. Since not all HCCs code does not fall into the hierarchy, the knowledge of the hierarchy of the HCC codes is vital when documenting any diabetic diagnosis.

5. What is HCC 17 in diabetes?

HCC 17 signifies Diabetes with Acute Complications in the diabetes hierarchical condition category, with 23 diagnoses within the spectrum. These 23 diagnoses cover inpatient hospitalization for a patient admitted to an emergency department.

Some of the diagnoses included in HCC 17 are diabetic hypoglycemia, ketoacidosis, and hyperosmolarity without or with coma. Most patients with these conditions often face life-threatening complications and must use extensive healthcare resources. Hence in the CMS HCC V24.0 risk adjustment factor, it is noted.

6. What is HCC 18 in the diabetes hierarchical condition category?

HCC 18 denotes Diabetes with Chronic Complications and has 400 different diagnoses. Under these diagnoses, the chronic complications include retinopathy, neuropathy, chronic kidney disease, etc.

It is a risk assessment model for patients susceptible to chronic conditions caused due to diabetes, like nervous, renal, and cardiovascular systems. Since many diabetic patients suffer from other complications concurrently, the clinicians are required to code and document the associated complications with the progression of diabetes to ensure risk adjustment and better care quality.

7. How is HCC 19 different from HCC 17 and HCC 18?

Under HCC 19, there are only six diagnoses. HCC 19 is the code that denotes Diabetes without Complication. In HCC 19, the diagnoses included are those that do not have other complications like those mentioned in HCC 17 and HCC 18. In this category, the diagnosis is associated with long-term insulin use. Within the hierarchy, it has the risk adjustment factor of the lowest, i.e., CMS HCC V24.0 of 0.105.

HCC 19 often requires a document specialist since it requires reviewing the documents and identifying indicators, abnormalities detected in the physical examination, and lab values so they can generate a diabetic-specific complaint query.

8. Are there any specific considerations for Diabetic HCCs coding?

The coding and documentation related to HCCs in diabetes must be completed at least once annually. When HCCs for diabetes are added, they must have the following:

  • Service date
  • Name and date of birth of the patient
  • Signature and credentials of the provider
  • When applicable legible handwriting
  • Abbreviations as per the industry standards
  • Statement of evaluation

9. How to ensure the HCC codes are followed correctly for a diabetic patient?

One of the best ways to ensure that the diabetic hierarchical condition categories (HCC) coding  are properly mentioned when it comes to diabetic billing and coding is by working with experts in the field of medical billing. One such expert is 24/7 Medical Billing Services, as they can ensure proper HCC codes are used during medical billing and coding to warrant appropriate and timely reimbursement for the services.

Read more: HCC (Hierarchical Risk Adjustment) – A Key To Coding & Care

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