HCC Coding Technology in the New Year

HCC Coding Technology

The New Year brings new opportunities and New Year resolutions. As a healthcare provider, what are your professional resolutions to drive change and improvement for your practice?

This blog post, the third of its series, will focus on an important topic for those providing services to Medicare Advantage patients: using technology to optimize the HCC documentation process and increasing RAF scores. We will talk about recent updates to the CMS-HCC program, as well as retrospective and prospective approaches towards risk adjustment analytics and coding.

HCC Coding in 2020

To get started with the topic of HCC Coding technology, let’s talk about some of the reasons why technology is important for your healthcare organization in the new year. One of the primary reasons includes staying up to date with CMS’ extensive policies and regulations. CMS requires that providers have a patient encounter each calendar year, and as mentioned in an article in ICD Monitoring, for HCC coding to be successful, “providers must report all diagnoses that impact the patient’s evaluation, care and treatment, including coexisting conditions, chronic conditions, and treatments rendered.” Providing specific and complete documentation of all diagnoses on an annual basis can be challenging for many practices. It is also challenging to keep track of yearly changes in policies. As announced in the 2020 Rate Announcement, this year CMS added a few disease categories to the main HCC model and added a condition count to account for how many conditions the patient has in total. More information about the announcement can be found on their website here.

Having the aid of HCC coding tools can facilitate documentation in new encounters starting the year while also taking into consideration any updates to CMS policies. The use of technology can also help with:

1. Automation of workflow that leads to more proficient documentation
2. Coders and provider collaboration
3. Reduced care gaps caused by insufficient provider documentation

Retrospective, Prospective, and Concurrent Approaches to Risk Adjustment

Before we discuss risk adjustment technology, it’s helpful to be reminded of what risk adjustment is and is not. Many in healthcare think of risk adjustment in clinical terms. While there are clinical elements to all risk adjustment models, such as diagnostic specificity, quality metrics, and care planning, risk adjustment is fundamentally an actuarial concept. Risk adjustment models, such as CMS-HCC, seeks to use the estimated cost of managing patients’ risk factors to establish payment levels. As mentioned by CMS, from a payer perspective, this levels the playing field by discouraging Medicare Advantage plans from cherry picking only the healthiest beneficiaries, and unfairly disadvantaging those that insure the most seriously at-risk enrollees.

The success or failure of risk adjustment modeling depends on the accuracy, thoroughness, and timeliness of patient information communicated to CMS. For payers and providers alike, compliance with the myriad of CMS guidelines is virtually impossible without extensive use of technology. This is especially the case when it comes to identifying all possible HCC coding opportunities throughout the calendar year.

Health plans aren’t the only ones auditing charts and analyzing claims information. Increasingly, providers are adopting the same tactics and using the same technology to optimize risk adjustment documentation. Identifying HCC coding opportunities generally fall into three approaches: retrospective, prospective, and concurrent.

    Retrospective Review

Anything retrospective involves a look back, so, for providers, a retrospective HCC coding review occurs after patient care has been delivered and claims information submitted to the payer. A comprehensive retrospective approach will review both patient charts and submitted claims data. A retrospective review aims to 1) identify unreported HCC codes that are supported in the patient’s chart, 2) review submitted HCC codes that did not meet CMS documentation guidelines, and 3) identify coding gaps, such as ICD-10 HCC diagnoses submitted by a provider other than the patient’s PCP, or diagnoses that were submitted in the previous calendar year that might apply to the patient in the current year.

A retrospective review is important because it gives providers the opportunity to correct previously-submitted HCC codes, as well as uncover problems with the organization’s risk adjustment program. On the other hand, retrospective reviews focus on information that’s potentially outdated, and they can be expensive, time consuming, and operationally burdensome if cost-effective and efficient technology is not used. They can also lead to “provider abrasion,” or conflicts between payer and provider organizations.

    Prospective and Concurrent Approaches

Although retrospective reviews are an essential part of the risk adjustment process, they should not be used exclusively. Adding prospective and concurrent reviews lessens the reliance on expensive and burdensome retrospective processes, improves operational efficiency, optimizes payments under risk-adjusted contracts, and helps improve payer-provider alignment. A prospective review occurs shortly before the patient’s visit with the provider. This approach examines all available patient information, including previously-documented HCC codes, to help the provider prepare for the scheduled appointment. Once the patient’s clinical and claims information has been analyzed, the provider is usually given a list of potential or suspected HCC codes to consider during the encounter.

A concurrent review takes after the patient encounter, but immediately before claims information is submitted to the health plan. This process helps improve HCC coding accuracy and ensures that supporting documentation adheres to CMS guidelines. Because the concurrent review happens in more or less “real-time,” analytics and computer-assisted coding technologies must be used to help providers and coders parse large amounts of clinical data. Combining prospective and concurrent reviews results in a much smoother process than if a retrospective review is used alone, not to mention less provider abrasion and higher risk adjustment payments.

When it comes to prospective/concurrent and retrospective reviews, Inferscience technology offers you the best of both worlds. With multiple workflow options, our HCC Assistant and HCC Validator solutions make prospecting and code validation quick and easy. Our Claims Assistant module analyzes claims data and shows potential HCC coding gaps to the user while working in their EHR workflow. While each application can be licensed separately, when used together they help identify HCC coding opportunities before, during, and after the patient encounter.

HCC Assistant

HCC assistant parses the patient chart and shows all possible HCC related diagnoses in real-time to the provider or the coder so that HCC opportunities are not missed while documenting the patient visit. Real time risk adjustment factor (RAF) scoring within the platform suggests how codes selected will impact the RAF score for a patient thereby predicting future funding and expenditures.

Features & Benefits:

1. Efficient workflow: User-friendly interface saves hours researching and documenting.
2. Turn-key: Web-based application means there is nothing to install or maintain.
3. Flexible: HCC Assistant can be accessed through your EHR, used as a standalone application, or integrated via API.
4. Advanced rules engine: Uses NLP and advanced coding algorithms to analyze charts in real-time.
5. Cost-effective: There are no hidden costs and simplified pricing means you pay only for what you need.

It is also important to mention that the HCC Assistant updates every year with any changes in CMS policies, so with the start of the year, it will suggest codes that include CMS changes in the 2020 rate announcement.

To make sure all documentation is reviewed and validated, Inferscience offers an add-on product to work with the HCC Assistant, the HCC Validator. The HCC Validator uses advanced NLP technology to instantly validate HCC codes against MEAT criteria and issues a clear “Pass” or “Fail” grade. Because it’s SaaS-based, it works with leading EHRs or can be used as a standalone solution.

Having the aid of an HCC Coding tools such as the HCC Assistant and HCC Validator can facilitate HCC Coding and Risk adjustment documentation in the new year to generate results that will drive change for your practice. If you’re interested in adding HCC Coding technology for your practice as one of your professional resolutions in 2020, reach out to Inferscience at or contact us at (617) 848 9502.

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