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Avoiding Common Pitfalls in HCC Risk Adjustment Coding Reviews: Tips and Tricks for Health Plans

Are you tired of sifting through mountains of coding reviews, only to find the same mistakes repeated over and over? As a health plan, it’s essential to ensure accurate hierarchical condition categories (HCC) risk adjustment coding reviews to protect your bottom line. But with so many potential pitfalls, it can be challenging to know where to start. 

Fear not! In this blog post, we’ll provide tips and tricks for avoiding common errors in HCC risk adjustment coding reviews. From documentation compliance to diagnoses specificity, we’ve got you covered. 

So put down that red pen and read on for some expert advice on streamlining your coding review process!

When it comes to HCC risk adjustment coding, there are a few common pitfalls that health plans should avoid.

Here are some tips and tricks for avoiding these pitfalls:

1. Make sure your coders are trained on HCCs.

2. Have access to a comprehensive HCC coding checklist.

3. Be sure to review all diagnoses, not just those that were reported on the claims.

4. Make use of technology in your HCC code review process

5. Review your denials and appeals to identify any potential issues with your HCC coding process.

Table of Content:

More about HCC Coding Review

A Health Care Coding Review (HCCR) is a process used by health plans to ensure that the diagnoses codes submitted by providers are accurate and complete. 

The goal of an HCCR is to improve coding accuracy and completeness, which in turn can improve risk adjustment payments made to the plan.

There are several different types of HCCR  that health plans can use, but all share some common features.

First, HCCRs typically involve a review of a sample of medical records. 

Second, they often include a desk review component, in which coders review the documentation and assign codes without actually reviewing the medical records. 

Third, HCCRs may also include on-site visits to provider offices, during which coders review medical records and interview providers.

The specific coding guidelines used in an HCCR will vary depending on the type of health plan being reviewed. For example, Medicare Advantage plans must follow CMS coding guidelines. However, all HCCRs share some common coding challenges, such as correctly identifying primary and secondary diagnoses, assigning correct codes for chronic conditions, and ensuring that codes are specific enough to capture the severity of the condition being treated.

Health plans can use HCCRs to improve their risk adjustment payments in several ways: 

First, they can use HCCRs to identify areas where their coding accuracy needs improvement. 

Second, they can use HCCRs to develop educational materials for providers on how to enhance coding documentation.

Common Challenges and Pitfalls in HCC Coding Reviews

One of the most challenging aspects of risk adjustment coding is dealing with the sheer volume of medical records. A typical HCC review can involve reviewing hundreds or even thousands of records. This can be daunting for coders, especially if they are not experienced in HCC coding.

Another challenge is that HCC codes are often very specific and can be difficult to remember. Coders may need to consult extensive code lists or reference materials frequently during a review.

Pitfalls in HCC coding reviews can include failing to capture all relevant diagnoses, double-coding diagnoses (i.e. assigning multiple codes for the same diagnoses), or miscoding diagnoses (i.e. assigning the wrong code). These errors can lead to under or over-reporting of risk scores, which can in turn impact a health plan’s reimbursement.

To avoid these challenges and pitfalls, health plans should consider using specialized HCC code review & audit tools that can help coders quickly and accurately identify relevant diagnoses in medical records. 

In addition, health plans should provide coders with adequate training on HCC coding guidelines and principles, and ensure that they have access to reference materials during reviews.

Best Practices for HCC Coding Reviews

There are a few best practices that health plans should keep in mind when conducting HCC coding reviews. 

First, it is important to have a well-defined review process in place. This process should be designed to target specific areas of the code set that are most likely to result in errors.

Second, health plans should make use of NLP-powered technology to identify potential coding issues. This can be done by looking for patterns in the data that indicate errors.

Third, when errors are identified, health plans should work with providers to correct them. This may involve providing education on proper coding practices or working with providers to update their records.

Finally, health plans should track the results of their HCC coding reviews over time. This will allow them to identify trends and adjust their review processes accordingly.

Tips and Tricks For Health Plans During HCC Audits

1. Know your HCCs: In order to avoid common pitfalls in HCC risk adjustment coding reviews, it is important for health plans to know their HCCs. This includes understanding which diagnoses fall into which HCC categories and being aware of any changes or updates to the HCC coding system.

2. Review claim data regularly: Another way to avoid common pitfalls in HCC risk adjustment coding is for health plans to review their claim data on a regular basis. This allows plans to identify any errors or discrepancies in the coding of diagnoses and can help prevent issues from getting worse over time.

3. Train providers on HCC coding: One of the best ways to avoid common pitfalls in HCC risk adjustment coding is to train providers on proper HCC coding practices. By ensuring that providers are knowledgeable about the correct way to code diagnoses, health plans can help reduce the likelihood of errors and improve the overall accuracy of their claims data.

4. Utilize technology: There are a number of different software programs and tools available that can help health plans with their HCC risk adjustment coding. Utilizing these tools can help streamline the process and make it easier for plans to avoid common mistakes.

5. Work with a reputable vendor: Finally, another tip for avoiding common pitfalls in HCC risk adjustment coding is to work with a reputable vendor who specializes in this area. A good vendor will have extensive experience with the HCC coding system.


Health plans should take a proactive approach to HCC risk adjustment coding reviews in order to avoid common pitfalls that can lead to inaccurate risk scores and lost revenue. 

By implementing the tips and tricks outlined in this article, health plans will be better prepared for future HCC risk adjustment coding reviews. 

And, with the right processes in place, health plans can ensure accurate coding and maximize their reimbursement potential.

Reach us to integrate NLP-powered HCC code review & audit tools within your risk adjustment workflow.


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Disclaimer: All the information, views, and opinions expressed in this blog are inspired by Healthcare IT industry trends, guidelines, and their respective web sources and are aligned with the technology innovation, products, and solutions that RAAPID offers to the Risk adjustment market space in the US.