Hayes' Healthcare Blog

The Basics

Hierarchical Condition Categories (HCC) were mandated in 1997 by the Centers for Medicare and Medicaid Services (CMS) and have been the basis for reimbursement for Medicare Advantage plans (MA) since 2004. HCCs use data to prospectively estimate predicted costs for enrolled members during the next year of coverage. These estimates are based on demographic information such as age and major medical conditions documented in the previous 12-month period. They are used to adjust Medicare capitation payments to Medicare Advantage health plans based on the anticipated risk of enrollees calculated from relevant ICD-10-CM codes.

Minimize Liability, Mitigate Risk and Maximize Safeguards

Corliss Collins, RHIT, CCA, CBCS, Senior Healthcare Consultant, AHIMA Approved ICD-10 Trainer /Ambassador

HIPAA compliance audits pose significant challenges for hospitals, healthcare providers, health plan administrators and business associates.  The Office of Civil Rights, (OCR) Phase II Audits will begin early this year and, will focus on organizational privacy, security, and breach notification policies, procedures and practices.

Healthcare organizations need to be prepared to undergo greater scrutiny in three key areas, including written policies, procedures and practices that address HIPAA compliance risks, and vulnerabilities. Are HIPAA compliance audits and risk assessments being performed regularly? How is documentation of HIPAA breach incidents within your organization responded to?

There’s a lot of confusion about coding right now and for good reason. Beginning a few weeks ago, June 1^st to be exact, many insurance carriers began accepting and processing preauthorization requests containing ICD-10 codes for services scheduled on or after October 1^st - the upcoming mandated ICD-10 compliance date. As with ICD-9 codes today, providers and suppliers are still required to report all characters of a valid ICD-10 code. However, ICD-10 diagnosis codes have different rules regarding specificity and providers/suppliers are required to submit the most specific diagnosis codes based upon the information that is available at the time.

The curfew for ICD-10 is fast approaching and with it comes a slew of changes for your documentation. Do you know what you’ll need for a successful implementation? Here are a few helpful suggestions: