Medicare Advantage enrollment has doubled over the past decade1 and is projected to increase by 51 percent by 2030.
HCC coding is used by any healthcare provider that accepts Medicare Advantage plans. Coding and revenue cycle leadership at MA organizations are probably well aware that there is always a high chance that error or missed risk-adjusted reimbursement if HCCs are not carefully audited internally prior to the initial sampling period under the CMS-HCC model.
Having delivered HCC Coding Services to facilities and health systems across the nation, we realize the complexities involved in understanding how the 9,700 ICD-10-CM codes map to one or more of the 86 HCC codes.
Inaccurate reporting or erroneous capturing of HCC codes can affect patient Risk Adjustment Factor (RAF) scores resulting in:
Consider following the below best practices to improve your organization’s HCC coding accuracy and maintain readiness for the annual Risk-Adjustment Data Validation (RADV) audits.
Risk adjustment and HCC coding relies on the abstraction of accurate and comprehensive documentation of chronic condition diagnoses by providers every year and combined for additive calculation. Providers need to verify that all the conditions of a patient are thoroughly assessed. In addition, the highest degree of specificity should be maintained during documentation. Remember, even the smallest differences in specificities can alter a patient’s treatment plans, code assignments, and RAF scores for predictive years.
Several healthcare organizations today implement policies that abide by the M.E.A.T criteria to ascertain the most accurate documentation for coding specificities.
This acronym stands for Monitoring, Evaluation, Assessment, Treatment which entails the following:
Physician documentation is key to HCC coding optimization. HCC Codes can only be optimized by increasing the level of specificity of the clinical documentation provided. Likewise, continuous ongoing education about HCC coding guidelines is essential for your coding team to apply the latest updated regulatory standards for high-quality scores. COVID-19 has also contributed to the added pressure physicians often feel when they are expected to focus on HCC coding regulatory upkeep in addition to the numerous responsibilities they already have on their plate.
Here are some tips for consideration as you navigate change management:
Provide regular training sessions to your coders so they stay up-to-date with these quarterly and annual updates and maintain compliance.
As part of our HCC coding Services, ECLAT Health Solutions provides education and training programs to your team. Stay vigilant for HCC codes concurrently if resources are available to reduce the time lag for upcoming reporting periods. Provide weekly or monthly mock audits with all participating parties and review the performance at the end of the mock audit so that changes based on the insights can be quickly implemented. All of this can help your organization avoid lost revenue opportunities prior to the reporting period.
This includes monitoring how provider education helped influence proper risk assessment for the future. It’s important to constantly monitor the success of your provider education program. Track KPIs including documentation completeness, reporting errors, claim denial rates, before and after the launch of the program. AHIMA also recommends that "Risk adjustment coding professionals should identify the documentation gaps and guide providers on how to eliminate the gaps"3
Lack of proper documentation and reporting of secondary diagnoses results in an incomplete picture of the patients and thereby becomes a common reason for loss of reimbursements. Pulling information from multiple data sources (hospital inpatient, hospital outpatient/ physician) can easily turn into missed opportunities for optimal reimbursement. Secondary and/or chronic conditions are often not reported especially in outpatient encounters. Part of this can be due to data interoperability, which is another important factor to take into consideration when reviewing the root cause of low-risk factor scores.
In order to overcome this, we usually advise and work with clients that are able to perform a secondary internal risk assessment review. This secondary review helps close the HCC documentation gaps that might have been missed in the primary risk assessment review.
Converting medical documentation into HCC codes is not as simple as it sounds. This tedious task requires specialized coding expertise and proficient experience with knowing where to search deeper for coding acuity, and raise awareness when needed. If you are not confident that you are reaping the benefits of optimal reimbursements, consider outsourcing certified risk adjustment coders who deliver consistent and compliant HCC coding performance. Partnering with a global HCC coding vendor helps release the administrative burden for providers sooner than later and allows them to focus on delivering better patient care.
The ECLAT medical coding and billing services team consists of credentialed AAPC and AHIMA coders who are specialized in coding services including HCC code assignment. We can help you feel confident about CMS Audit samples prior to submission deadlines to obtain optimal reimbursement. Learn more about our HCC coding services and witness the ECLAT advantage to optimize value-based reimbursement.
For any questions regarding our Risk Adjustment services or HCC Coding availability for outsourcing, click here.
Reference:
1. Kaiser Family Foundation (KFF), 2020 report.
2. Source: American Academy of Professional Coders
3. AHIMA - Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories
4. CMS Report