Submitted by Jay Snyder, DO FACP, Augusta Health Primary Care
As providers in our ACO we have been aware of the significance of HCC scores for a while now. This is something that hopefully we are all continuing to work on improving. The following are some ways to improve HCC scores in Athena.
First, as a reminder, all scores go back to ZERO on January 1st of each calendar year. AMG has now been using Athena for over 2 years so hopefully many diagnoses will already be in the system. It is important to re-capture these diagnoses if they are still active & proper diagnoses for our patients.
An easy way to review previously captured diagnoses is to look at the top of the screen at the Assessment & Plan page. You can click on the red link of potential diagnoses to evaluate whether or not we’ve been missing something relevant in 2019.
Specialists & urgent care providers, if you see a lot of potential diagnoses with a high Gap # that are likely still active & the patient does not have a follow-up with their PCP in 2019, please try to get them in for a visit with their PCP to see if these can be captured. One way to do this is to give them the # for centralized scheduling (833) AHC-HLTH (242-4584) which you can simply do by showing it to them on the top of their patient plan after your visit OR by sending a case directly to CENTRALIZED SCHEDULING STAFF who can call the patient. If your patient doesn’t have a PCP, CENTRALIZED SCHEDULING STAFF can help arrange that as well.
In addition to diagnoses that have been captured in the past two years, there are potential diagnoses from some specialists outside of Athena including Meditech that are in the charts now as well. We also have had some of them “TEE’D UP” by manual entry by Sisleidy Reyes (sreyes64). Certainly these need to only be added as a true diagnosis at your discretion. If you have concerns about any diagnoses you can also email Dr. Barb Fenton for clarification. (Below is a diagnosis that I had some questions about – it can possibly be added if a person requires multiple adjustments to their thyroid dose in a year.)
Diabetes is one of the most important diagnoses when it comes to HCC scores, especially in documenting complications. This far into the year if your patient has diabetes & doesn’t have an appt with their PCP it’s a good idea obviously for their overall well-being but also capture of HCC scores to get them back. Also of note there is another diagnosis in diabetes that we haven’t been capturing much & that is if they are on insulin.
For dialysis patients, be sure that you are documenting their dependence on dialysis in addition to their chronic kidney disease with:
*End stage renal failure on dialysis N18.6 (CKD Stage 5 N18.5 is a duplicate & not needed)
*Dependence on renal dialysis Z99.2
Be aware that Arteriovenous fistula, acquired I77.0– IS NOT AN APPROPRIATE WAY TO DOCUMENT THIS SO DON’T USE THIS DIAGNOSIS
Depression is a common diagnosis that should be captured as well. Be careful as there are many commonly used diagnoses for depression that don’t count. This includes the very commonly used Mixed Anxiety and Depressive Disorder. As you can see below this is not associated with any HCC score.
The correct way to document depression is as follows:
First list depression.
Then click on the red link will bring up the following:
You can then choose the diagnosis you would like.
(Clicking the HCC RAF tab can be helpful also in this process.)
Mood disorder also can count.
For patients on controlled substances for more than 12 weeks such as opioids (including Tramadol), benzodiazepines & sedatives we can also use diagnoses that capture this.
In patients with a history of substance abuse it is also appropriate to document even if it is a “history of,” just as we previously discussed other “history of” including the very important diagnosis of history of toe amputation. (Look how high the HCC/RAF score is on history of toe amputation!)
We have previously reviewed some nuances in patients with Coronary Artery Disease & whether or not that can be captured. However, it’s also important to know that if a patient has atherosclerosis of the aorta documented evidence on imaging (CT, US etc) we can capture this.
We can even capture abdominal aortic ectasia.
Another important cardiovascular diagnosis overlooked that can be used is diastolic heart failure.
Lastly be sure that if any diagnosis you choose that is a chronic medical problem that it is saved to the chronic medical problems list.
Hopefully this has been a worthwhile update & review.