The Changing Role of the Provider in HCC Coding

When it comes to clinical documentation, today’s healthcare providers have more to worry about than simply capturing their patients’ diagnoses and services rendered. Provider groups of all sizes are assuming risk in value-based contracts, and with that comes complicated coding and clinical documentation requirements driven by programs such as Medicare Advantage.

Risk adjustment documentation is difficult without the use of electronic health records, so clinicians are increasingly tied to the computer to successfully manage patients enrolled in risk-based plans. Once hailed as the solution to save time spent researching and recording patient information, EHRs are implicated as a leading cause of physician burnout. In fact, about 54% of U.S. physicians experience burnout tied to EHR use, and that percentage will likely increase as HCC coding requirements are added to their already documentation-heavy workflows.

The first in a series of three, this blog post discusses the basics of HCC coding, while subsequent posts will discuss how to equip physicians to succeed in today’s value-based marketplace, including optimizing EHRs to actually save time documenting for risk adjustment, instead of contributing to physician burnout.

HCC (Hierarchical condition category) is a risk-adjustment model that helps estimate patients’ future healthcare costs and determines funding of Medicare Advantage plans from Medicare . Medicare calculates a Risk Adjustment Factor score for a patient based on their demographics and the HCC codes billed by the provider. The risk adjustment score is then used by CMS to determine the payment to Medicare Advantage Plans.

Although HCC coding is essential to maximizing reimbursement and improving patient care, it has the potential to contribute to physician burnout. Some of the challenges physicians face specific to HCC coding and risk adjustment are:

It is complicated & time-consuming. Providers often don’t have the time to research optimal HCC codes to document in the patient encounter notes before claims are submitted.

Spending too much time in clinical documentation can take away from patient care. Documentation is often suboptimal without appropriate HCC codes and detailed plan of care information. Trying to “untangle the web” can take away from patient care.

It’s challenging to capture everything, which leads to lost revenue. Even when spending a lot of time documenting, it’s hard to capture everything, as some diagnosis codes can still fall through the cracks. Inaccurate documentation results in lower patient RAF scores and reduced payments, which means loss of revenue.

On top of these challenges, the reality is that most providers dislike the documentation process. If you ask a physician why they chose their career, it’s unlikely they will reply, “because I really enjoy documentation.” Regardless of its lack of popularity amongst clinicians, physicians play a key role in HCC coding documentation, especially when practicing under the Medicare Advantage program.

1. Providers stand at the front of the HCC coding process. The best moment for capturing accurate HCC codes is during the patient encounter. Accurate first-pass documentation at the point of encounter helps streamline the claims process by aligning payers and providers. This reduces “chart chasing,” costly audits, and expensive clawbacks.

2. Accurate HCC coding helps improve patient care. Accurate HCC coding helps close gaps in care because emphasis is placed on documenting all chronic conditions and care plans on an annual basis. This results in better patient engagement and, if needed, referrals for specialist care.

3. Better HCC coding results in higher reimbursement. According to Amerigroup, “The Centers for Medicare and Medicaid Services (CMS) base each member’s overall health status on the conditions identified and supported in their medical record.” Consequently, the severity of the patient’s health status determines the risk adjustment funds provided by CMS. It is key for providers to document all patients’ health conditions with enough specificity in order for CMS to fund appropriately based on the patient’s disease burden.

At the end of the day, clinicians’ level of accuracy in HCC coding and supporting documentation not only impacts patient care, but ensures that provider organizations receive proper credit for the value of care provided.

We’ve established the importance of HCC coding and optimal documentation, its challenges, and the role of the individual provider, but how do we make it easier for clinicians to stay current with regulatory changes and adhere to CMS’s documentation requirements? How do we help providers improve their HCC coding? Our next blog post will cover how to equip providers and motivate them to take a more active role in HCC coding and risk adjustment.

About the Author

Lucy Medina is an experienced healthcare marketer with expertise in payer contracting and revenue cycle management. She joined Inferscience in the spring of 2019. Inferscience offers an HCC Coding tool that integrates with leading EHRs and HIT systems to analyze patient records and claims information to help physicians and coders capture and audit HCC codes within their workflows. With Inferscience’s HCC Assistant, Physicians can document HCC codes and plan of care information in real-time during the patient encounter. Now, one solution enables both payers and providers to succeed in today’s value-based care market.
Learn more about Inferscience and HCC Coding Assistant by visiting our products page here.

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