The HCC recapture rate indicates how many recurring or chronic conditions or diagnoses a healthcare provider resubmits to the CMS every twelve months. Failing to resubmit this data against the HCC list of diagnoses would mean that the information is removed from the patient’s Medicare record, reducing the patient’s risk score and financial healthcare treatment cost predictions.
A recapture rate of 85% or above is commonly seen as sufficient because this reduces the potential that a proportion of patient risk scores will be adjusted downward. A 100% recapture rate would indicate that all ongoing diagnoses have been correctly reported.
HCC coding for providers relies on healthcare organizations submitting accurate, consistent medical data. An ongoing diagnosis for a life-long or progressive condition will not be resolved or cease to exist from one year to the next, so it is the provider’s responsibility to document that diagnosis every year.
Re-documentation is a Medicare requirement, with the industry standard benchmark of 85%, as mentioned above. This means that at least 85% of recurring diagnoses should be correctly coded once per annum.
Consistency is just as vital as accuracy because the goal of HCC codes and risk adjustment scoring is to ensure there is a dependable and quantifiable field of data to help predict future healthcare costs with a strong degree of precision. Where a healthcare provider maintains excellent HCC coding data and record-keeping, the patient risk scoring and the financial benchmarks allocated should remain stable, a key requirement for a value-based healthcare system.
If a diagnosis is not recaptured using the appropriate HCC code, the patient’s risk score will drop, and financial benchmarks will be reduced. For the provider, that translates into lower reimbursements and reductions in financial resource allocations.
Risk Adjustment Factors (RAFs) are designed to absorb differences in real-world healthcare and treatment costs between patients and use numerical scoring assigned to specific HCC codes to create an outline of the future costs of meeting a patient’s needs. Note that risk adjustment isn’t solely about conditions and diagnoses, but it also incorporates other factors that influence treatment costs, such as demographics and socioeconomic status.
RAF scoring is fundamentally important to the financial viability and security of healthcare organizations, particularly those with larger patient groups who have more complex needs and, therefore, may require greater expenditure. By ensuring HCC codes are correctly recaptured and reported every year and that the organization maintains a good recapture rate, the healthcare provider will document a better picture of the patient’s health profile and be able to rely on accurate RAF scoring.
One of the most effective ways to address lapses or gaps in HCC recaptures is to use a data aggregation solution that can capture and categorize data from patient records across the healthcare space–without depending solely on in-house patient medical records. Technology-based tools are often seen as the best option because these resources can perform rapid, multi-patient assessments simultaneously and use logical reasoning to ensure all possible gaps within clinical documentation are identified and resolved.
The Inferscience software system can flag a repeating HCC diagnosis, ensure diagnoses and treatments are accurately coded, and contribute towards consistent, best-practice risk adjustment scoring based on reliable coding recaptures. Reach out today for more information or to request your free demo!
References:
https://jdc.jefferson.edu/ms_opx/3/
