Success Codes—Patient Condition Count Edition

You can be forgiven if you missed it among all your holiday frivolity, but CMS released a proposal for the latest risk-code update.  It’s significant.


And I read it so you don’t have to.


The bottom line?


If adopted, pay special attention to collecting all the HCC groups for your dual-eligible patients—that’s where the low hanging fruit is.



  1. There are two proposed models under discussion—one that includes two additional conditions (pressure ulcer codes and dementia) and one that does not.
  2. Both will award “extra” risk scores for the number of HCC groups submitted for the patient—not risk codes, HCC groups. The more HCC groups associated with a patient, the higher the risk scores. The bonus starts with patients who have codes that map to a total of 4-5 HCC groups  (depending on demographics) and max out at 10 HCC groups or more.
  3. The “extra” conversion factors are different for each beneficiary group—they are higher in “dual-eligible” disabled patients and least in the “aged-in” population.
  4. These are proposals only, the final rule will be released in 90-120 days
  5. If accepted, the revised coding system will be phased in over three years 2020-2023.



That’s what the battlefield looks like—more on tactics next week.