2014 CMS-HCC Model Changes

Date Issued: 10/18/2013

The Centers for Medicare & Medicaid Services (CMS) has revised its Hierarchical Conditions Category (HCC) codes for 2014. The new model includes changes to existing HCC codes as well as newly added codes. Here are some highlights:

Revisions to the HCC Groupings in the 2014 CMS-HCC Model

  • HCCs renumbered so that similar categories are closer together
  • 79 HCCs – up from 70 in 2013 – as a result of new HCCs and division of several existing HCCs
  • 225 ICD-9 codes added from 14 CMS-HCC categories
  • 134 ICD-9 codes dropped from 11 CMS-HCC categories

Additions and Deletions to the 2014 CMS-HCC Model

  • Morbid obesity 278.01 – Morbid obesity and other significant endocrine and metabolic disorders are new.

Body mass index (BMI) and pressure ulcer stage code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., the patient’s physician or other qualified health care practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., dietitians often document BMI and nurses often document pressure ulcer stages). Note: The associated diagnosis (such as obesity, morbid obesity or pressure ulcer) must be documented by the patient’s provider.

Morbid obesity defined as BMI 40 or greater V85.41-V85.45 
V85.41 BMI 40.0-44.9, adult 
V85.42 BMI 45.0-49.9, adult 
V85.43 BMI 50.0-59.9, adult 
V85.44 BMI 60.0-69.9, adult 
V85.45 BMI 70.0 and over, adult

Note: Code first the morbid obesity 278.01.

  • Exudative macular degeneration 362.52 – Exudative macular degeneration is new. It includes macular degeneration, documented as disconfirm macular degeneration or wet macular degeneration.
  • Fibrosis of the lung and other chronic lung disorders – These lung disorders are new. Hypoxemia was removed, so document the specificity or reason for the hypoxemia.
  • Chronic kidney disease – CKD stage 1-3, unspecified renal failure and nephritis were removed. Stage 4, stage 5 and end-stage renal disease were added.
  • Common diagnoses – Common diagnoses added include:

    135 Sarcoidosis 
    238.4 Polycythemia vera 
    252.00 Hyperparathyroidism 
    252.1 Hypoparathryroidism 
    252.8 Parathyroid disorder NEC 
    252.9 Parathyroid disorder NOS 
    253.8 Pituitary disorder NEC 
    253.9 Pituitary disorder NOS 
    255.0 Cushing’s syndrome 
    278.03 Obesity hypoventilation syndrome (Pickwickian syndrome) 
    282.40 Thalassemia NOS 
    282.41 Sickle-cell thalassemia without crisis 
    282.42 Sickle-cell thalassemia with crisis 
    287.30 Essential thrombocythemia 
    287.5 Thrombocytopenia 
    362.01 Background diabetic retinopathy (diabetic retinopathy NOS) 
    362.07 Diabetic macular edema (use with codes 362.01-362.06 diabetic retinopathy) 
    366.41 Diabetic cataract 
    454.0 Varicose veins of lower extremities included stasis dermatitis 
    454.2 Varicose veins of lower extremities with ulcer and inflammation 
    494.0 Bronchiectasis without acute exacerbation 
    494.1 Bronchiectasis with acute exacerbation 
    516.31 Idiopathic pulmonary fibrosis

Documentation significantly impacts patient care, coordination, coding, billing and compliance. Note: CMS requires supportive documentation and coding to accurately describe the patient’s health status to the highest level of specificity. It is imperative to document the patient’s conditions appropriately both on the claim submitted to EmblemHealth and in the patient’s medical record.

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