HCC coding is critical to RAF scoring and reimbursement under value-based care contracts. It requires high accuracy and attention to detail, as ICD-10 codes require more specificity than previous versions.
Ensuring your team captures a clearer picture of enrollee health can help improve risk adjustment scores and program success. To do this, build systems that focus on coding accuracy and prioritize improvement efforts year-over-year.
Electronic Health Records
Healthcare organizations need to optimize their EMR, data, and analytics to enable better documentation of chronic diseases. This enables better HCC risk adjustment coding and more accurate reimbursements for quality care. HCC coding requires medical coders to thoroughly review charts to ensure all diagnoses submitted for risk score calculation are current, accurate, and specific enough to accurately portray a patient’s RAF (risk score). The hierarchical condition category coding is based on ICD-10-CM, and what might be adequate to establish medical necessity for claims submission is not necessarily sufficient to support a diagnosis for RAF calculation. HCCs are additive, so a single patient could have several conditions that map to the same HCC. Incorporating external data into HCC risk adjustment models can improve coding accuracy and increase a provider’s monetary earnings. However, ensuring this data is secure and meets applicable privacy regulations is important. A trusted healthcare IT partner can help with this. They can also create a dashboard highlighting problems, such as duplicate diagnoses, or a problem list that’s not as targeted as it should be for HCC coding.
HCC coding is critical to financial success under risk-adjusted reimbursement contracts as the healthcare industry shifts to value-based care and payment models. With HCCs influencing revenue and clinical performance, it’s critical to understand how your organization is currently performing to identify opportunities for improvement. Thorough clinical documentation of patient conditions is essential for accurate HCC coding. This includes capturing cause-and-effect relationships and documenting all active diagnoses for each encounter. It’s also important to document all current conditions contributing to a patient’s risk, as HCCs reset annually.
It’s also critical that all HCC codes are documented to the highest level of specificity, particularly in EHRs, where the search list for diagnosis codes often places unspecified codes at the top of the list. This can impact the overall accuracy of HCC coding because a code not documented to the highest degree of specificity will be less valuable in the RAF scoring process.
The primary way HCC coding impacts reimbursement is through the accuracy of diagnoses submitted for risk score calculation. This is a key reason that many health plans and HCC vendors develop provider documentation programs to educate providers in improved documentation practices to describe their patients’ diagnoses with increased specificity. These programs can also provide the training needed to improve a physician’s ability to identify comorbidities and accurately code them.
As value-based healthcare moves to the forefront, it is essential that providers fully understand how HCC coding impacts their reimbursement. HCC coding can help communicate a patient’s complexity to payers by reporting accurate, current, and supported ICD-10-CM codes. Since HCCs reset each calendar year (CY), ensuring that all current conditions affecting a patient’s care and management are reported is critical. The goal is for a health plan to have the most complete and accurate picture of a member’s health status when they submit their HCC score to the government oversight agency.
HCC coding impacts reimbursement differently than fee-for-service (FFS) coding. The primary way it impacts reimbursement is through the accuracy of diagnoses submitted to the government’s risk adjustment agency. Correct diagnosis coding drives accurate risk scores that affect how much providers receive for their services in value-based payments. To capture HCCs correctly, coders must be trained in all aspects of the coding process. This includes a thorough understanding of the official coding guidelines and CMS expectations and a working knowledge of medical documentation. In addition, a coder needs to know how to identify specific clinical concepts documented with different terminology and varying degrees of negation.
For example, the root clinical concept of breast cancer can be documented in a variety of ways in a patient’s chart and can be used with negation terms such as “no,” “not,” or “can’t.” This variability must be recognized to ensure an HCC is properly captured. A specialized HCC coding training course focuses on these issues to support a healthcare organization’s successful risk adjustment coding process.
The right technology platform can support a program’s coding efficiency and accuracy. Look for a system that leverages data-driven insights from natural language processing, machine learning, and artificial intelligence to structure clinical and claims data for actionable results. A high-impact technology solution can help identify missed HCC conditions and close documentation gaps faster than a traditional review. This could mean the difference between achieving or missing transfer payment reimbursements.
Some technologies also provide a unified coding environment, presenting coders with the tools and information they need in an easy-to-use interface. This helps streamline workflow and reduces the need to switch between applications, eliminating potential error-prone manual processes.
The best coding solutions also provide real-time validation checks, catching errors and inconsistencies in the process rather than after the fact. This prevents downstream issues such as claim denials and delays in reimbursement. Some also offer provider documentation guidance that teaches physicians to describe diagnoses with greater specificity and clarity, helping ensure more accurate risk adjustment codes and documentation. This, in turn, leads to better reimbursement for the health plan and providers.