HCC specific documentation criteria

In my last blog, HCCs: An awareness perspective, I introduced you to Mike, a 66-year old white male with type II diabetes mellitus (DM) and congestive heart failure (CHF). I set the tone for what an individual patient experience may look and/or feel like leading up to the primary care provider (PCP) face-to-face office visit. 

Mike was seen by his PCP for a very mild increase of shortness of breath upon exertion over a two to three week time frame. Today, Mike remains quite well, with diagnostic descriptions that fall into hierarchical condition category (HCC) 18: diabetes with chronic conditions, and HCC 85: congestive heart failure, respectively. 

What should Mike’s PCP consider when documenting his chronic conditions specific to diabetes, heart failure and disease interactions? How might this overall patient experience impact the required PCP face-to-face interaction? What are the key HCC documentation requirements that must be captured to better understand and focus on the sickest patients; ultimately reducing costs and improving quality care and patient outcomes?  

First, it remains clear that the Centers for Medicare and Medicaid Services (CMS) requires documentation in the individual patient’s medical record by a qualified health care provider to support the submitted diagnosis. This specific documentation must support the presence of the condition and indicate the provider’s assessment and/or plan for management of the condition. This documentation must occur at least once each calendar year for CMS to recognize that the patient continues to have the condition. 

Additionally, the HCC diagnosis must be captured in a face-to-face visit by a qualified physician or non-physician provider (NP, PA, CRNA) and must be appropriately documented in the patient’s medical record. The HCC diagnosis must provide supporting clinical evidence for all diagnoses and, once again, be clearly documented. 

Lastly, the provider must show evidence that the individual patient’s conditions met what is called M.E.A.T (Monitoring, Evaluation, Assessment, Treatment) criteria during Mike’s PCP visit.  

In my third and final HCC blog post, I will present a clinical case scenario and examples of what specific M.E.A.T criteria and the associated risk factors would look like based on Mike’s HCC diagnoses, chronic conditions and what his provider must capture to provide supporting clinical evidence for his diagnoses of type II diabetes and CHF.  

Until next time … like Mike, please be well! 

Richard Wetherbee is a clinical performance improvement specialist 3M Health Information Systems.