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By Helen Gelly, MD
Most people these days know their Credit Score. There are “apps” to check it and to improve it, even though it may be calculated in a complex way from a lot of factors. And even though the financial impact of a low credit score may be indirect, most people know it is real. There is another score that affects the financial health of medical practitioners, and that is their Hierarchical Condition (HCC) Score. The Centers for Medicare and Medicaid Services (CMS) has implemented the calculation of HCC scores for every beneficiary it covers. Since patients with chronic conditions tend to be higher consumers of health care dollars, CMS uses HCC scores to predict the cost of care for the following year for these beneficiaries.  When CMS implemented Medicare Advantage (MA) plans, there was a concern that healthier patients would be cherry-picked by these plans. If all patients were assigned an average per-capita payment, then the Advantaged plans would have no incentive to care for more complex patients.  To minimize this risk, HCC scores for beneficiaries form the basis for higher payments based on their risk-adjusted scores. Each practitioner is assigned an HCC score, which is the average of all the HCC  scores of their individual patients. It tells CMS how sick your patients tend to be, and whether the Medicare spending attributed to YOU makes sense in relation to the complexity of your patients.
CMS now has extensive experience in predicting prospective costs for each beneficiary. It also has a way to assign medical complexity (a way to measure general “sickness”). When MIPS was implemented, one of the components of the calculation was the HCC score.  Although the final calculation is murky to the general public, inevitably, the complexity of your patients will impact the bottom line in the calculation of how much of the expected resources you are using for a given beneficiary based on HCC (but also in comparison to your medical specialty – which is a separate problem).
It is becoming increasingly important to know what your HCC score is and to make sure that you accurately capture the conditions that have the most significant impact on your score. In a way, the physician’s HCC score reflects both how sick his/her patients are, and how well the doctor documents these conditions in the electronic health record. For example, in a diabetic with a foot ulcer, comorbid conditions impact the adjustment score such as: chronic obstructive pulmonary disease, chronic heart failure, and dialysis. However, an accidental laceration does not.  As wound care and hyperbaric medicine practitioners, we treat complex patients with serious problems. It is to our benefit to document these conditions, because that’s what in part “explains” why expensive treatments are needed.
You can think about your HCC score like your credit score. You can go through life ignoring it, but if your score is low because of poor data you can correct (and you don’t correct it), a low score will ultimately have a negative effect on your finances—even if the monetary impact of the HCC is indirect and complicated (and we are not sure we fully understand it).
To further explore the HCC categories see:
https://www.ccwdata.org/documents/10280/19002246/ccw-medicare-risk-score-user-guide.pdf
To identify recognized ICD-10 codes that map to HCC categories:
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors-Items/RiskModel2019.html

To find out your HCC score for 2017 and the years prior, follow these easy steps:

Step 1. Go to: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicare-provider-charge-data/physician-and-other-supplier.html

Click on: Medicare Physician and Other Supplier Data CY 2017


Step 2. Open Page: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier2017.html


Step 3: Click on View Data, and enter your NPI


Step 4: Open your Excel Spreadsheet and review (for example, here’s Dr. Caroline Fife’s HCC).

And here it is!

What’s your HCC?

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