There are a several mission critical areas involved in the management of HCCs (hierarchical condition categories) that include employee engagement, accurate patient documentation and effective auditing processes that would facilitate a positive financial impact.  Depending upon the effectiveness of the HCC program, HCC’s can help capture lost revenue dollars and identify areas of revenue risk as well. The challenge in the management of HCC’s is in the details. Providers are required to report patient information and their findings accurately. It cannot be stressed enough that to obtain the most accurate payment in risk adjusted environments, one must have accurate and complete documentation. 

Five Words to Ensure HCC Accuracy

Remember these five words to ensure the highest level of HCC accuracy is being met: Document, Enter, Capture, Assign, and Use.

  • Document refers to documenting in the medical record that a patient’s conditions were Monitored, Evaluated, Assessed, and or Treated, (MEAT) within a calendar year.
  • Enter is referring to the providers entering the highest disease categories for their patients. This would include the proper documentation of all complications or comorbidities.
  • Capture refers to the documentation of the severity and stage of chronic conditions. For example, documenting that a patient has stage II chronic kidney disease would be an appropriate way to capture information and would allow for predictions of future healthcare needs and costs.
  • Assign is referring to coders assigning a specific ICD-10 code for every diagnosis documented in the patient medical records. This step is one of the most important in relation to the implementation of HCCs because diagnoses are the means in which HCC’s are calculated. The final of the five words is use.
  • Use refers to using qualified coders to select the correct codes for a specific diagnosis.  At the end of the day, HCC accuracy and effectiveness depends largely on the providers ability to document the patient’s care accurately and the coder’s abilities to apply the correct codes based on the documentation received. 

The most vital part of the HCC process is ensuring all patients classified as “at-risk or risk-adjusted” patients have a face to face visit on an annual basis. The biggest mistake that can be made is to wait until the end of the year to figure out these patients need to be seen. The best practice is to schedule appointments with your “at-risk” patient population as early in the year as possible.  The purpose of these appointments is to ensure their care is documented, their active conditions have been updated, documented properly and coded for timely reimbursement. In addition, patients without a validated treatment plan should be contacted. Taking a proactive approach to patient outreach helps ensure that patients appointments will be set earlier rather than at the end of the year.

Strategic Implementation

Finally, let’s consider how the strategic implementation of audits will elicit a positive financial impact. Before we discuss auditing, one must understand that HCCs allow for appropriate MA plan reimbursement by calculating a risk adjustment factor (RAF). A RAF, simply put, is a risk score. Proper implementation of auditing can allow companies to fine-tune these risk scores. This means that the absence, lack of quality and accuracy when coding can cause significant revenue to be left uncaptured. Proper coding can be the difference in tens of thousands and possibly even millions of dollars over time if it is not done accurately. To counteract this risk, companies should identify gaps in care, and gaps in documentation and codes that impact quality scores and payment. To identify these gaps, companies should conduct retrospective audits on data submitted to payers.

Prospective audits should be considered and conducted prior to submission of a claim to a payer. Conducting prospective audits can also lower CMS/RADV audit risks. An auditor should then review the record to ensure the ICD-10 codes and CPT (Current Procedural Terminology) meet payer guidelines. In the event an error is identified, it should quickly be fixed before the bill is submitted for payment. Ultimately, a prospective audit aims to achieve three things for an organization. First, it should examine the efficacy of existing HCC coding programs within their institution while identifying the best practices for documenting and coding. Second, it should provide a review of the overall accuracy of its coder while ensuring accurate quality scores. And third, it should help to maximize performance of the organization and ensure appropriate care for patients while maximizing financial reimbursement.