HCC coding profoundly impacts healthcare, influencing patient outcomes, provider reimbursement, and resource allocation. Health plans must ensure that all diagnoses submitted to CMS or HHS for risk adjustment are accurate, current, and supported in physician documentation. Your organization requires administrative, clinical, and supplemental data to do so.

HCC Coder

Hierarchical condition category (HCC) coding is the core of risk adjustment and is vital to the value-based care reimbursement model. This process uses data collected from claims and medical records to determine a patient’s health risk and assign them a payment rate. It is necessary to ensure that patients receive appropriate care and that healthcare providers receive accurate reimbursement. You can enhance your practice’s revenue cycle and prevent claim denials by appropriately documenting HCC coding and risk adjustment.

As more and more physicians move to value-based contracts, your organization must be ready for these changes. HCC coding is a must to succeed in these new models, as it helps payers understand your patient’s total cost of care and predict future prices. HCC coding also determines the overall RAF score, calculating your payor’s reimbursement.

To boost your HCC coding efficiency, it is essential to have a consistent review process that can be performed concurrently and in real-time. This can reduce the rework and alternate submission forms required to adjust initial claims. Ensuring that an HCC code supports all diagnoses documented in the chart is also essential. Incorrect diagnosis coding can result in underpayments to your health plan and may impact the quality of care you can provide your patients.

HCC Auditor

While some aspects of healthcare have clear procedures and rule sets, others require human judgment. This is particularly true in HCC coding. A few minor differences in interpretation or application can have a significant impact.

Fortunately, there are methods for increasing HCC coding accuracy and lowering the risk of coding errors. 

 One key is utilizing a robust HCC audit and compliance service. These services can help identify coding gaps and educate providers on documenting and coding accurately. They can also support clinical staff, such as CDI managers and physicians, to ensure they meet coding guidelines.

Another critical factor is understanding how HCCs impact the RAF score and reimbursement. HCC coding is only accurate when the totality of the patient’s health status and history are considered.

This requires a comprehensive, proactive approach that identifies EHR and claims data gaps. It includes implementing a workflow to identify patients not documented and coded for a full calendar year. It is accomplished using a clinical dashboard combining EHR and claims data to identify these patients.

The underlying problem for these individuals is that they have yet to be thoroughly evaluated or treated. A thorough risk-adjusted review can result in better per-member cost calculations and fairer compensation for the healthcare organization. It can improve care quality, patient outcomes, and operational efficiency.

HCC Analyzer

HCC coding is the cornerstone of risk adjustment in Medicare Advantage and value-based healthcare. It communicates patient complexity and paints a picture of the medical record while accurately predicting healthcare cost utilization. It can have a significant impact on revenue cycle performance for healthcare organizations.

Risk adjustment impacts the reimbursement a health plan receives for the care it provides its members. Health plans must accurately report all HCC diagnoses documented in their member’s medical records to CMS or HHS to obtain the proper reimbursement. Failure to do so can result in underpayment and deter the ability to offer quality healthcare to patients.

The HCC Analyzer is a medical coding software solution that allows health systems to identify missed RAF opportunities by analyzing historical clinical records and identifying missing code combinations. It uses sophisticated algorithms to find various ICD codes that satisfy the coding criteria and maximize RAF scoring. It also helps identify potential RAF opportunities that could have been avoided with more thorough documentation or by using different disease groupings.

The software is a powerful tool for improving accuracy and speed in coding and maximizing risk adjustment scores. It is built by medical coders for medical coding. It minimizes clicks and sub-searches to make it easier for coding professionals to be more productive and efficient in capturing a patient’s RAF score.

HCC Compliance

HCC compliance is critical to risk adjustment and can affect healthcare organizations’ financial viability. As more and more health plans move to value-based care, it becomes even more critical for them to meet HCC compliance standards. The more accurate and complete the HCC coding is, the higher the health plan’s risk-adjusted reimbursement.

Health organizations must improve their coding and auditing procedures to meet HCC compliance standards. They must ensure that all diagnosis codes are appropriately documented and matched with the appropriate ICD-10-CM code. It includes capturing complex and chronic disease states with co-morbidities (e.g., heart failure and hypertension). Documentation should also reflect that the condition is active or in remission.

As with many areas of the healthcare industry, human judgment plays a vital role in achieving compliance standards. This is especially true of the nuances involved in the coding process, where each coder interprets rules and guidelines differently. It is where outsourcing to an experienced third-party provider can be beneficial for healthcare organizations.

Educating physicians is another crucial factor in improving coding accuracy. Physicians must be reminded to select the most specific and complete diagnosis from a templated drop-down menu. They should also be warned about the temptation to copy and paste since this can result in unspecified and over-coded diagnoses.