What Is Retrospective and Prospective Coding?

Coding is an extremely important aspect of the modern healthcare industry because it helps healthcare providers understand their patients better so that they can accurately predict their future medical needs.

Risk adjustment coding enables medical professionals to predict their future resource utilization so they get reimbursed appropriately for their services. As a healthcare service provider, you must ensure that the healthcare payment claims you submit are error-free.

Therefore, it’s important to thoroughly review or audit your claims to avoid delays in submission and reimbursements, which can negatively impact your facility’s finances and ability to operate. Errors in your hierarchical condition category (HCC) coding can lead to external audits or fraud investigations, which are stressful and will delay your reimbursements.

This is why you must do everything possible to prevent coding errors, and the best way to avoid these errors is to review HCC codes. The two most important HCC coding review processes are prospective and retrospective coding reviews. 


What Is a Prospective Coding Review?

A prospective coding review is the process of analyzing your HCC codes before you submit your healthcare payment claims. The main objective of a prospective coding review is to catch coding or billing errors before the submission is made.

This coding review focuses mainly on specific and targeted cases chosen in accordance with the guidelines issued by the Office of the Inspector General. These cases can also be selected from high-risk areas you identified from previous external audits.

Your risk adjustment coders will evaluate the patient’s HCC codes, prescriptions, medical records, test results, and doctor notes to establish the correct risk factors for your billing and payment claims. During this process, ensure that your coders don’t miss any essential codes. 

Missed HCC codes can negatively impact your finances because you won’t be reimbursed appropriately. You must also ensure that HCC codes have been properly documented and recorded in the patient record.


What Is a Retrospective Coding Review?

Retrospective coding is the process of reviewing HCC coding information after you’ve delivered the necessary medical services and submitted your healthcare payment claims. This process helps to uncover any HCC codes that were missed during the submission as well as any HCC codes that shouldn’t have been included.

Failure to comply with the HCC code documentation guidelines can have serious consequences, including fraud investigations. Because the retrospective process happens after the fact, if there are any documentation issues uncovered, they may end up being a longstanding and ongoing problem you will need to spend precious time dealing with.

Retrospective coding also needs a secondary procedure to highlight the wrong codes and resend the claim with the correct codes to the payers. This coding process is common with Medicare Advantage plans. 

Medicare Advantage plans use the Alternative Submission Method, and it’s not difficult to submit retrospective HCC code adjustments. Unfortunately, this process can be quite cumbersome with other payment plans.


Which One Works Best?

For the Medicare Advantage plan, the prospective coding process can seem cumbersome and superfluous at first. However, prospective reviews are less disruptive than retrospective reviews and can yield great operational and monetary benefits because it makes sure the codes are right before submission.

This minimizes time wasted because you don’t have to do corrections and do-overs after submission. If you do proper prospective HCC coding, there won’t be any need for retrospective coding. It also helps you avoid disruptive external audits and fraud investigations because you get your payment claims right the first time.

With the help of advanced HCC coding solutions like Inferscience, you can carry out your prospective and retrospective coding quickly and accurately to avoid delays in reimbursements, as well as to improve overall patient care.





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