How does CMS collect a patient’s HCCs for risk scoring?
CMS collects a patient’s HCCs from corresponding ICD-10-CM codes submitted on claims for inpatient, outpatient and physician encounters. If a patient’s condition was not recorded on a submitted claim but is appropriately documented in the medical record as verified by a Peoples Health review of the patient’s chart, CMS will allow us to submit the code that indicates the presence of the condition, and the HCC weight for the condition will be included in the patient’s risk score.
What is the purpose of the chart reviews Peoples Health conducts?
Peoples Health conducts chart reviews to look for documentation of “suspects”—patients suspected to have conditions that map to HCC codes, but whose recently submitted claims lack appropriate coding for these conditions. This process serves as a safeguard to verify that information related to risk scores, as well as quality and HEDIS measures, is recorded in the patient’s medical record and reported to CMS.
How are suspects determined for chart pulls?
Suspects for chart pulls are identified through either or both of the following:
- Records show the patient had a claim for a specific chronic condition in the past, but that same condition has not been coded on a claim this year. (Please note, you may not have been the physician who coded the original condition.) If your records show this patient is in your panel and has received treatment from you, medical record review is necessary to determine whether the missing diagnosis is documented in the records and can be appropriately coded on your behalf during the record review. Additionally, results from labs and tests, along with medication, can potentially indicate suspects for certain conditions.
- Peoples Health records indicate the patient is showing gaps in care for one or more HEDIS measures. This information may be contained in the patient’s medical record and can be extracted and appropriately coded on your behalf during the record review.
As the patient’s health plan, in accordance with HIPAA, Peoples Health has the right to review and request these records.