Point-of-care HCC coding surfaces and documents diagnoses in real time, inside the EHR, while the patient is still in the room. Here is how it works and why it beats the retrospective chart chase.
Let's talkPoint-of-care HCC coding identifies, confirms, and documents a patient's conditions during the visit, so diagnoses are captured with clinical evidence while the encounter is still open and documentation can still be corrected at the source.
It is the opposite of retrospective coding, which reviews charts weeks or months after the visit to recover diagnoses that were missed. Point-of-care coding runs in real time inside the EHR, so the provider reviews suggested HCCs and documents them in the note during the encounter.
Conditions are documented while the clinical evidence is fresh and the provider is engaged, so fewer supportable diagnoses slip through.
Every code ties to a real encounter with MEAT support, which holds up as RADV audits expand and unlinked chart review is phased out.
Strong point-of-care programs can cut retrospective workload by 30 to 50%, according to industry analyses, by closing gaps during the visit.
Coding happens inside the existing workflow in under 10 minutes, instead of pulling providers into query fatigue weeks later.
Inferscience's HCC Assistant is a point-of-care HCC coding tool that runs inside athenaOne, Epic, and eClinicalWorks.
It uses natural language processing to read structured and unstructured chart data, applies clinical rules to catch overlooked diagnoses, and surfaces HCC suggestions in real time during the encounter. The provider reviews the evidence behind each suggestion and makes the final call, at 98% coding accuracy. HCC Validator then confirms MEAT support before submission, so documentation is defensible. A 700-provider clinically integrated network has coded this way with Inferscience inside athenaOne since 2020. Read the case study →
See also: Prospective vs. retrospective HCC coding.
Point-of-care HCC coding captures and documents a patient's diagnoses during the visit, in real time inside the EHR, while documentation can still be corrected at the source. It contrasts with retrospective coding, which reviews charts after the encounter.
Point-of-care coding happens during the visit and produces more complete, more defensible documentation. Retrospective coding reviews charts weeks or months later to recover missed diagnoses, and only works after documentation is already set.
CMS is phasing out unlinked chart review and expanding RADV audits, so every HCC increasingly has to trace to a documented encounter. Capturing diagnoses at the point of care is the most reliable way to meet that bar.
No. With Inferscience, the tool does the chart analysis automatically and surfaces ready-to-review suggestions, so providers code in under 10 minutes inside their existing workflow.
HCC Assistant runs inside athenaOne, Epic, and eClinicalWorks, and offers an API for payers and third-party vendors.
We'll show HCC Assistant surfacing diagnoses during the visit, in your workflow.
Let's talk