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HCC Gaps

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How to Resolve HCC Gaps: Best Practices for Healthcare Providers

Clinicians no doubt play a vital role in recording patients’ conditions using HCC codes, but they shouldn’t shoulder the challenging coding aspects alone.

Moreover, accurate HCC coding is vital for value-based care models and population health management. Incomplete coding can affect reimbursements and suboptimal decision-making. With the expanding scope of value-based care contracts, adopting and refining measures to close HCC gaps is the need of the hour to enhance revenue and ensure optimized reimbursement.

Importance of HCC Coding underlying the risk adjustment process

Hierarchical Condition Category (HCC) coding communicates patient complexity and portrays a holistic patient health condition. Based on precise HCC coding, RAF scores predict healthcare resource use, enabling risk-adjusted quality and cost metrics.

Certainly, HCC coding helps to consider patient complexity, which ensures a more accurate measurement of quality and cost performance.

Risk adjustment is a method to project future health expenditures for entities like Medicare Advantage, ACA Marketplace, and ACO providers. Various contracts employ distinct risk adjustment models utilizing ICD-10-CM codes that aggregate to specific Hierarchical Condition Category (HCC) codes. These HCC codes signify chronic conditions linked to specific Risk Adjustment Factor (RAF) scores. A total RAF score is derived by summing individual RAF scores considering demographic factors, convertible to an expected per-member annual health expenditure.

Carefully designed HCC coding solutions can relieve in-house medical coders of compliance concerns and streamline patient data review and chart audit processes. Additionally, HCC coding services can enhance meeting tight project deadlines.

Let’s discuss some of the prime areas that address HCC coding gaps, assisting healthcare providers in optimizing reimbursements and averting revenue loss.

Tips to manage HCC Gaps that Ensure Complete Code Capture

1)  Enhance Documentation Practices

Ensure thorough data collection from all sources using effective forms like Patient Assessment Forms (PAFs) or Comprehensive Health Assessments (CHAs). Optimize medical record review processes while upholding high-quality standards in delivering HCC coding projects.

RAAPID’s AI-powered Prospective Previsit Solution is powered by clinically trained NLP to analyze comprehensive longitudinal data, including charts, claims, lab reports, and pharmacy records. It seamlessly integrates with Electronic Health Records (EHR) and automates the precise chart review process.

2)  Highlight Specific Coding

Lack of a thorough and accurate understanding of the health and risks in a patient population may lead to decreased reimbursements and suboptimal decision-making for interventions and investments. Emphasize the importance of coding specificity for accurate RAF scores. Encourage physicians to be exceptionally detailed when documenting diagnoses for precise value assignment and risk determination. Clinical teams are urged to code with precision. In the ICD-10-CM system, diagnoses are intricate.

For example, A patient with minimal severe health issues might anticipate average medical expenses for a specific period. Conversely, patients with numerous chronic conditions would likely incur increased healthcare utilization and costs.

3)  Take advantage of technology

Conduct medical chart audits to prevent under-coding or selecting incorrect ICD-10-CM and HCC codes from causing overclaiming. Streamline the review of Medicare patient data from various sources with a centralized solution, automating chronic condition identification and validation.

Nevertheless, It will be a good measure to adopt an industry-proven HCC Coding technology for efficient EMR/EHR optimizations, seamlessly integrating with various systems and suggesting accurate HCC risk adjustment codes for arriving at precise RAF score calculation.

4)  Regularly Validate Data

Adhering to the CMS HCC payment model, providers should annually report all chronic conditions and co-morbidities to the highest level of specificity. Therefore, factoring chronic conditions into risk adjustment calculations through chart reviews must occur annually. Ensure consistent data revalidation, follow-ups to monitor patient health conditions, and flag patients missing annual visits for scheduling wellness check-ups.

5)  Empower Teams Through Education

Offer comprehensive support to providers for accurate HCC documentation. Provide thorough training and furnish specialized automation technology for enhanced efficiency. If required, supplement support staff, including HCC coders and care coordinators

6)  Prepare for patient visits in advance

The pre-care team can assist providers in identifying patients with HCCs before their visits to enhance the effectiveness of chart preparation, problem list reviews, and morning huddles.
Ideally, the care team should initiate chart preparation approximately one week before the scheduled appointment.

Thus, the above-mentioned measures emphasize the importance of accurate Hierarchical Condition Category (HCC) coding. This is essential to depict a comprehensive picture of a patient’s health, especially regarding the prolonged complexity of treatments required for specific diagnoses of chronic conditions  & proper claim submissions.

Accurate data collection and complying with new rules for coding and implementing HCC codes can be easily achieved by deploying tools like those provided by RAAPID’S solution space, which forms the key to ensuring  HCCs and risk adjustment factor (RAF) scores are precise. They can, therefore, predict outcomes that may change the value of provided care.

To learn more about RAAPID’s Solution, Speak to an Expert Now.


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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.