With the rise of high deductible health plans, friction between payers and providers is higher than ever. Ineffective collaboration can negatively impact patient outcomes and revenue for both parties. The HCC model organizes ICD-10 diagnosis codes into “families” that can be used to estimate a patient’s risk score. This allows for accurate reimbursements under capitated payment models.
How Does HCC Coding Optimize Risk Adjustment?
As the healthcare industry transitions from a fee-for-service model to a value-based care (VBP) paradigm, a key component of this shift is the inclusion of risk-based payment models. This shift requires health plans to assume some financial risks associated with their patient populations. This is accomplished by incorporating a risk score metric into all VBP programs.
To determine a patient’s risk score, the Centers for Medicare & Medicaid Services uses diagnosis codes – known as hierarchical condition category coding – to identify a patient’s chronic medical conditions. These HCCs are then grouped by CMS and used to estimate the cost of caring for each beneficiary. The result is an overall risk score called a Risk Adjustment Factor (RAF) determining a patient’s capitation payments.
The higher a patient’s RAF score, the more costly it is for the insurance company to cover their medical needs. As a result, the insurance provider will require additional payments to offset this expense. As a result, capturing accurate HCCs is the key to achieving and maintaining a high-risk adjustment score. Providers must ensure that all diagnoses are properly captured and documented within the EMR system. When HCCs are recorded accurately, patient outcomes and reimbursement improve. This is particularly important when addressing complex patient populations such as those in Medicare Advantage Plans.
HCC Coding is the Great Equalizer
As the healthcare industry shifts from fee-for-service to value-based care, HCC coding has taken on new significance. As the Centers for Medicare & Medicaid Services (CMS) estimates anticipated costs for Medicare Advantage plan participants, HCC documentation directly impacts healthcare organizations’ reimbursement.
With reimbursements tied to specific diagnoses, it’s imperative that a health plan’s HCC coding program accurately documents all chronic conditions, acute care needs and medications used for a patient. Achieving this level of accuracy requires the right mix of administrative, clinical and supplemental data to enable better documentation, improve disease characterization and uncover gaps in risk adjustment coding that could result in inaccurate RAF scores and improper payments and reimbursements.
Consider this scenario: Patient A is a 90-year-old woman with multiple chronic conditions, including diabetes, COPD and coronary heart disease. Her health team documented her condition status during face-to-face encounters using ICD-10 coded diagnoses, physician notes and medical record review. Patient B, also an 80-year-old, is diagnosed with a similar set of conditions but does not have these conditions documented to the same degree of specificity.
Because RAF scores are applied prospectively, it’s important that each coding session is complete and accurate to ensure the most accurate picture of patients’ overall healthcare costs and quality performance. The more details documented, the more precise the resulting image of the patient’s healthcare complexity – and the more valuable the risk-adjusted payment for physicians.
HCC Coding is the Key to Value-Based Care
A key piece of the healthcare industry’s shift toward value-based care is a focus on risk adjustment and reimbursement. HCC coding is at the heart of that, allowing payers to accurately communicate patients’ risks and predict healthcare costs, which is vital for patient population health management.
The HCC model assigns a risk-adjusted factor (RAF) to patients, which Medicare Advantage and commercial payers use to determine capitation payments to health plans for each Medicare Advantage or Medicare Managed Care enrollee. To maximize reimbursements, a health plan must ensure that all patients are appropriately coded and documented each calendar year (CY). Please do so to avoid underpayment to the project, which can ultimately impact a healthcare organization’s financial viability and quality of care.
A health plan that optimizes HCC coding and documentation should prioritize ongoing training and education for its coding and clinical teams. This ensures the team members are updated on coding guidelines and methodologies, enabling them to work more efficiently and effectively. It also helps to develop systems that promote thorough coding and documenting for encounters to capture better the full picture of the patient’s medical needs and risks, which can then be translated into accurate HCC codes. This will help to ensure a smooth and effective reimbursement process and pave the way for success in today’s evolving healthcare environment.
HCC Coding is the Key to Revenue Cycle Performance
The HCC coding process is a critical component of revenue cycle management for healthcare organizations. With accurate and timely coding, providers can receive appropriate reimbursements for their care. Therefore, it is important that medical coding and billing staff are properly trained to understand the nuances of this process and ensure compliance with regulatory guidelines.
HCC coding requires thoroughly reviewing each patient’s medical records to identify and code relevant diagnoses submitted to CMS or commercial risk adjustment programs for calculating RAF scores. This is a time-consuming and labor-intensive process.
Since each diagnosis is assigned a unique ICD-10-CM code, physicians must document the condition correctly to include it in an individual’s risk score. Documentation should accurately describe the severity of the patient’s disease, e.g., mild (m), moderate (m), severe (s), or very severe (v).
The documentation linked to a non-specific diagnosis or incomplete documentation will negatively impact the patient’s RAF score and reimbursement. The good news is that technology can help healthcare organizations improve HCC coding accuracy. For example, using technology to help coders detect missed or incorrect diseases in the medical record, or utilizing a digital clinical documentation system that provides decision assistance tools for specific diagnoses, can enhance medical coding accuracy and ensure an appropriate risk adjustment score.