If you haven’t been overly concerned about hierarchical condition categories (HCCs) over the years, you’re not alone. But now more than ever, as value-based reimbursement models take root and expand, organizations that want to survive and thrive need to recognize how much is at stake if they don’t adequately document and code for HCCs.
The stakes are high. If you under-code or under-document, you’ll end up with a lower risk score and an underpayment. But if you over-code and are later audited, you may end up having to pay a significant penalty. It can be a major challenge, because coding is complicated and time-consuming.
HCCs are challenging in part because they identify risk for a given patient over an entire year, covering all inpatient, outpatient and physician office settings. To be accurate, every diagnosis for which that patient is treated, evaluated and/or monitored must be tracked. The combination of disease risk and demographic risk determines the patient’s risk-adjustment factor (RAF), which is used to predict how much it will cost to care for that patient.
Far too often, conditions are under-coded by providers who fail to document complications. Diabetes is a classic example. Providers who always default to diabetes without complications, either because that’s what they’re used to doing, or because their electronic health record (EHR) doesn’t properly prompt them, will end up leaving reimbursement funds on the table. The RAF for diabetes without complications is 0.182. For diabetes with either acute or chronic complications, it’s 0.474.
But to code correctly, providers need to establish a direct correlation between the condition and the complication or manifestation, using, for example, a phrase like “due to,” “caused by,” or “secondary to.” So, a diabetes patient is said to have “stage IV chronic kidney disease due to diabetes.”
The fact is, even the most conscientious providers can easily miss the diagnostic code that reflects the highest specificity of disease burden, and inaccurately document the encounter. Multiply that number by multiple physicians and multiple patients and the potential for lost revenue is profound.
What steps can you take to make sure you get the reimbursements you have coming to you?
- Educate staff and standardize procedures: Top-level coders may understand the guidelines to follow when they report diagnoses and procedures, but don’t assume office staff or physicians have the same level of understanding. And no matter how good your coders are, if physicians aren’t sufficiently thorough, coders can’t assign the proper HCCs.
- Expand your data sources: Claims data may not be enough. EHRs provide a broader view of a patient’s overall disease state.
- Conduct audits: An HCC oversight committee may be able to spot common oversights or gaps that can then be used to target educational efforts and reminders. Committee members should concentrate on high-risk patients who are most likely to have gaps.
Trained medical scribes from ScribeAmerica can provide the critical support physicians need to ensure that every encounter is accurately documented in EHRs and that all conditions are monitored, evaluated, addressed and treated (the “MEAT” that supports HCC codes). ScribeAmerica training emphasizes RAF-HCC accuracy and documenting for the highest disease specificity. And since many scribes hope to have careers in medicine, they’re eager to learn more about disease acuity. By collaborating with physicians, they help paint a detailed picture of the patient’s disease burden, and how each condition is being managed, which is crucial for proper reimbursement.
ScribeAmerica Navigators, once embedded within your care team, can also help bridge the gap between providers and patients. They’re trained to update EHRs to reflect the most accurate HCCs, co-existing conditions and population health trends. They can also ensure that high-risk patients are seen at least once during the calendar year, report complications that occur between visits, set referral appointments and preventative screenings, and identify “rising risk” patients.