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Hierarchical Condition Category API

Hierarchical Condition Category (HCC) coding is a risk adjustment payment model mandated by the Centers for Medicare and Medicaid Services (CMS). There are more than 9000 ICD-10 codes that map to more than 70 HCC codes in the model. CMS requires documentation of the person’s condition at least once each calendar year to ensure reimbursement.

Hierarchical Condition Category

HCCs in the HealtheIntent Hierarchical Condition Categories solution are represented as persistent diagnoses and suspected conditions. A persistent diagnosis is a previously documented condition tied to an HCC not yet documented this calendar year. A suspected condition is a condition not diagnosed or documented for the person, but suspected based on laboratory results, medications, and procedures. Both supporting and possible competing clinical facts are provided to facilitate decisions around a suspected condition.

The HCC object

Example HCC object

{
  "diagnosis_code": "E13.9",
  "code": "HCC 17, 18, 19 Diabetes",
  "diagnosis_code_description": "Other specified diabetes mellitus without complications",
  "diagnosis_code_system_id": "2.16.840.1.113883.6.90",
  "last_service_date": "2018-03-12T05:00:00.000Z",
  "status": "PENDING",
  "aliases": [
      "HCC_18_DIABETES_WITH_CHRONIC_COMPLICATIONS_CLIN",
      "HCC_19_DIABETES_WITHOUT_COMPLICATION_CLIN"
  ],
  "stratification": "Highly Suspected",
  "stratification_category": "HIGH",
  "supporting_facts": [
    {
      "name": "insulin_present",
      "value": "true",
      "last_service_date": "2014-04-22T06:00:00Z"
    },
    {
      "name": "meglitinide_present",
      "value": "false"
    },
    {
      "name": "sulfonylurea_present",
      "value": "false"
    },
    {
      "name": "thiazolidinedione_present",
      "value": "false"
    },
    {
      "name": "incretin_mimetic_present",
      "value": "false"
    },
    {
      "name": "metformin_present",
      "value": "false"
    },
    {
      "name": "dipeptidyl_peptidase_inhibitor_present",
      "value": "false"
    },
    {
      "name": "amylin_analog_present",
      "value": "false"
    },
    {
      "name": "alpha_glucosidase_inhibitor_present",
      "value": "false"
    }
  ],
  "competing_facts": [
    {
      "name": "gestational_diabetes_present",
      "value": "false"
    },
    {
      "name": "pcos_present",
      "value": "false"
    },
    {
      "name": "pregnancy_present",
      "value": "false"
    }
  ],
  "types": ["PERSISTENT", "SUSPECTED"]
}
Name Type Description
diagnosis_code string Previously documented diagnosis code (ICD-9 or ICD-10)
code string HCC code number and description
diagnosis_code_description string Description of the previously documented diagnosis code
diagnosis_code_system_id string The coding system ID of the diagnosis code
last_service_date string The date and time (ISO 8601 format) of the most recent visit or condition
status string Indicates the status of the condition.
Possible values:
  • PENDING
  • SATISFIED
aliases array All the HCC code aliases that are relevant for a condition
stratification string Indicates the extent to which the condition is suspected based on the supporting and competing facts.
Possible values:
  • Highly Suspected
  • Moderately Suspected
  • Not Suspected

Note: This field is being deprecated in favor of stratification_category.
stratification_category string Indicates the category of suspected conditions of a person based on the supporting and competing facts.
Possible values:
  • HIGH
  • MODERATE
  • NONE

Note: This field is only present in the response object if Cerner has implemented a suspected condition algorithm for the HCC. The suspected condition algorithms use clinical data to identify potentially undiagnosed or undocumented conditions.
supporting_facts array Clinical facts supporting a suspected condition

Note: This field is only present in the response object if Cerner has implemented a suspected condition algorithm for the HCC. The suspected condition algorithms use clinical data to identify potentially undiagnosed or undocumented conditions.
competing_facts array Clinical facts disputing a suspected condition

Note: This field is only present in the response object if Cerner has implemented a suspected condition algorithm for the HCC. The suspected condition algorithms use clinical data to identify potentially undiagnosed or undocumented conditions.
types array The type of the condition.
Possible values:
  • PERSISTENT
  • SUSPECTED

Retrieve HCC

Example Request

curl -H 'Authorization: auth_header' https://cernerdemo.programs.healtheintent.com/api/populations/1424e81d-8cea-4d6b-b140-d6630b684a58/people/53580e0b-3170-42fe-80cf-9cd4685f6d4f/hcc_diagnoses
require 'httparty'

HTTParty.get(
  'https://cernerdemo.programs.healtheintent.com/api/populations/1424e81d-8cea-4d6b-b140-d6630b684a58/people/53580e0b-3170-42fe-80cf-9cd4685f6d4f/hcc_diagnoses',
  headers: { 'Authorization' => 'auth_header' }
)

Example Response

{  
  "conditions":[  
    {  
      "diagnosis_code":"E11.9",
      "code":"HCC 17, 18, 19 Diabetes",
      "diagnosis_code_description":"Type 2 diabetes mellitus without complications",
      "diagnosis_code_system_id":"2.16.840.1.113883.6.90",
      "last_service_date":"2016-02-01",
      "status":"PENDING",
      "aliases":[  
        "HCC_19_DIABETES_WITHOUT_COMPLICATION_CLIN",
        "HCC_17_DIABETES_WITH_ACUTE_COMPLICATIONS_CLIN",
        "HCC_18_DIABETES_WITH_CHRONIC_COMPLICATIONS_CLIN"
      ],
      "stratification":"Highly Suspected",
      "supporting_facts":[  
        {  
          "name":"metformin",
          "value":"true",
          "last_service_date":"2018-06-12T14:00:00.000Z"
        },
        {  
          "name":"hba1c",
          "value":"6.8",
          "last_service_date":"2017-08-15T19:20:00.000Z"
        },
        {  
          "name":"hba1c",
          "value":"6.5",
          "last_service_date":"2017-05-18T03:07:00.000Z"
        }
      ],
      "stratification_category":"HIGH",
      "types":[  
        "PERSISTENT",
        "SUSPECTED"
      ]
    },
    {  
      "diagnosis_code":"K50.80",
      "code":"HCC35 Inflammatory Bowel Disease",
      "diagnosis_code_description":"Crohn's disease of both small and large intestine without complication",
      "diagnosis_code_system_id":"2.16.840.1.113883.6.90",
      "last_service_date":"2017-11-30T16:18:00.000Z",
      "status":"PENDING",
      "aliases":[  
        "HCC_35_INFLAMMATORY_BOWEL_DISEASE_CLIN"
      ],
      "types":[  
        "PERSISTENT"
      ]
    },
    {  
      "diagnosis_code":"L97.529",
      "code":"HCC161 Chronic Ulcer of Skin, Except Pressure",
      "diagnosis_code_description":"Toe ulcer",
      "diagnosis_code_system_id":"2.16.840.1.113883.6.90",
      "last_service_date":"2017-05-18T12:24:00.000Z",
      "status":"PENDING",
      "aliases":[  
        "HCC_161_CHRONIC_ULCER_OF_SKIN_EXCEPT_PRESSURE_CLIN"
      ],
      "types":[  
        "PERSISTENT"
      ]
    }
  ]
}

GET https://{client}.programs.healtheintent.com/api/populations/{population_id}/people/{person_id}/hcc_diagnoses

Retrieves the suspected and persistent HCCs for the person within a population.

Path Parameters

Parameter Description
population_id The HealtheIntent population ID
person_id The HealtheIntent person ID

Query Parameters

Parameter Description
type OPTIONAL Filters conditions to only those of a certain type for the given person. All conditions are returned if you do not set this parameter.
Allowed:
  • persistent
  • suspected
status OPTIONAL The status query parameter is relevant only if type is set to persistent. Filters conditions to only those in a certain status for the given person. Conditions with a status of pending are returned if you do not set this parameter. You can filter only persistent conditions by statuses. If you set the type parameter to suspected, all suspected conditions are returned regardless of the status parameter you set.
Allowed:
  • pending
  • satisfied
  • all

Responses

Status Type Description
200 Hierarchical Condition Categories Collection of Hierarchical Condition Category objects
400 string Bad Request
401 string Unauthorized
403 string Forbidden
404 string Not Found
500 string Internal Server Error

The Risk Adjustment Factor (RAF) Scores object

Example RAF Scores object

{
  "raf_scores": [
    {
      "type": "ACTUAL_CMS_RAF",
      "display": "Actual RAF",
      "value": "0.300"
    },
    {
      "type": "POTENTIAL_CMS_RAF",
      "display": "Potential RAF",
      "value": "1.480"
    },
    {
      "type": "POTENTIAL_CMS_RAF_WITH_SUSPECTED",
      "display": "Potential RAF with Suspected",
      "value": "1.875"
    },
    {
      "type": "CLINICALLY_VALIDATED_ACTUAL_CMS_RAF",
      "display": "Clinically validated RAF",
      "value": "0.350"
    }
  ]
}
Name Type Description
type string The type of RAF score. Possible values are :
  • ACTUAL_CMS_RAF: The CMS RAF score after administrative validation has been performed. Administrative validation should be performed for data originating from adjudicated professional and facility billing claims.
  • POTENTIAL_CMS_RAF: The potential CMS RAF score calculated for HCCs that are not acute conditions, have been identified in the current or previous years, and have not been sufficiently validated this calendar year.
  • POTENTIAL_CMS_RAF_WITH_SUSPECTED: The potential CMS RAF score calculated for HCCs that have suspected condition algorithms, are not acute conditions, have been identified in the current or previous years, and have not been sufficiently validated this calendar year.
  • CLINICALLY_VALIDATED_ACTUAL_CMS_RAF: The CMS RAF score after clinical validation has been performed. Clinical validation should be performed for data originating from diagnoses made by a qualified provider during a qualifying patient encounter either using visit diagnoses from the electronic health record (EHR) or from outgoing Electronic Data Interchange (EDI) 837 transactional claim files.
display string The display text of the type of RAF score
value string RAF score value

Retrieve RAF Scores

Example Request

curl -H 'Authorization: auth_header' https://cernerdemo.programs.healtheintent.com/api/populations/1424e81d-8cea-4d6b-b140-d6630b684a58/people/53580e0b-3170-42fe-80cf-9cd4685f6d4f/raf_scores

require 'httparty'

HTTParty.get(
  'https://cernerdemo.programs.healtheintent.com/api/populations/1424e81d-8cea-4d6b-b140-d6630b684a58/people/53580e0b-3170-42fe-80cf-9cd4685f6d4f/raf_scores',
  headers: { 'Authorization' => 'auth_header' }
)

Example Response

{
  "raf_scores": [
    {
      "type": "ACTUAL_CMS_RAF",
      "display": "Actual RAF",
      "value": "0.300"
    },
    {
      "type": "POTENTIAL_CMS_RAF",
      "display": "Potential RAF",
      "value": "1.480"
    },
    {
      "type": "POTENTIAL_CMS_RAF_WITH_SUSPECTED",
      "display": "Potential RAF with Suspected",
      "value": "1.875"
    },
    {
      "type": "CLINICALLY_VALIDATED_ACTUAL_CMS_RAF",
      "display": "Clinically validated RAF",
      "value": "0.350"
    }
  ]
}

GET https://{client}.programs.healtheintent.com/api/populations/{population_id}/people/{person_id}/raf_scores

Retrieves the RAF scores data for a person based on population_id and person_id.

Path Parameters

Parameter Description
population_id The HealtheIntent population ID
person_id The HealtheIntent person ID

Responses

Status Type Description
200 RAF Scores Collection of RAF Score objects
401 string Unauthorized
403 string Forbidden
404 string Not found
500 string Internal server error