Advanced Revenue Cycle Analytics: An Overview

As Risk Adjusted Coding gathers steam, I get more questions about HCC coding.  Today, we are going to look at some specific strategies for improving HCC Coding for clinical staff.  Most clinicians do not have a lot of experience with HCC Coding.  The term HCC Coding may be new, but the concept is probably familiar.  HCC Coding is the preferred methodology for measuring patient acuity.  The two major components of a patient’s HCC score are demographic factors + diagnosis history.  If you need it, here is a refresher on the basics of HCC Coding.

To improve HCC coding for clinical staff the three strategic pillars are education, documentation and coding.

Education

Part of the challenge for practice leaders is the history of diagnosis coding under fee for service.  Traditional fee for service emphasized diagnosis coding in support of medical necessity.  CPT codes, fee schedules and RVU drive reimbursement under fee for service.  Diagnosis codes play a supporting role to justify the CPT code.  The fee for service created a paradigm for the clinical staff where diagnosis coding had a very small impact on the revenue cycle.

Value Based Reimbursement compares actual outcomes and costs to expected costs.  HCC Coding helps government and commercial payers understand patient acuity and project future healthcare costs.  Physicians often complain that their patients are sicker than those of their peers, or sicker than the payers think they are.  A key point to remember is that payers only have the data that is submitted on claims.  If you didn’t code it, it didn’t happen!

Areas of HCC Coding Impact:

  1. MIPS Score – Cost Measures
  2. Cost Effectiveness – Physicians Compare Website
  3. Reimbursement on Medicare Advantage Plans
  4. Reimbursement on Risk Adjusted Commercial Payer Plans

 

Documentation

Most practices do a good job of documenting patient comorbidities.  In fact, 52% of practices report that their physicians document patient comorbidities on most patient encounters.  This is an important step and an area of improvement for some clinical teams.  The “golden rule” of coding still applies, it cannot be coded if it is not first documented.

If you are working to improve comorbidity documentation in your practice, it is helpful to have a baseline.  A few good questions to ask to get the process started are:

  1. How well does our documentation reflect actual patient acuity?
  2. How frequently are we documenting patient comorbidities today?
  3. Which physicians do this well, where are there opportunities to improve and share best practices?
  4. What comorbidities do we do a good job of documenting?

Coding

While most practices accurately document patient comorbidities, only 18% report that they consistently code these comorbidities.  Old habits die hard!  Remember payers are using the diagnosis collected on claims to calculate HCC scores.  Diagnosis codes need to be reported at least once each calendar year to count towards the patient HCC score.

Best practices for capturing comorbidities:

  1. Display Patient HCC score at the time of service
  2. Display potential comorbidities
  3. Make it easy for clinical staff to select appropriate comorbidities (let doctor’s be doctor’s not coders!)