Five Action Items to Improve HCC Coding Accuracy and Risk Adjustment With Analytics

As enrollment in Medicare Advantage plans increases, healthcare organizations need to be able to anticipate future healthcare financial resources and predict appropriatereimbursementfor physicians. The Hierarchical Condition Category (HCC) risk adjustment model is used by CMS to estimate predicted costs for Medicare Advantage beneficiaries, and the results directly impact the reimbursement healthcare organizations receive. The HCC risk adjustment model wasoriginally implemented in 2004，但随着基于价值的支付模式的普及，它变得更加流行。

The HCC model assigns a Risk Adjustment Factor (RAF) to each Medicare patient as measurement of probable costs, which is then used to adjust capitation payments for patients enrolled in Medicare Advantage plans. According to theAmerican Academy of Family Physicians, “hierarchical condition category coding helps communicate patient complexity and paint a picture of the whole patient,” helping to appropriately measure quality and cost performance. Consequently, accurate HCC coding and risk adjustment can have a significant impact on healthcare organizations’ financial viability and care delivery.

HCC Model Complexities and Risk Adjustment Use

CMS requires that all qualifying conditions be identified each year by provider organizations. Documentation linked to a non-specific diagnosis, as well as incomplete documentation, negatively affects reimbursement. Healthcare organizations that optimize their EMR, data, analtyics, and education can enable better documentation of care for patients with chronic diseases, leading to more accurate HCC risk adjustment coding, and more appropriate compensation for quality care.

The number of Medicare Advantage beneficiaries has continued to rise over the past ten years, withroughly one-in-three Medicare beneficiaries现在加入了医保优势计划与启动任何新的计划一样，HCC编码并不直观，但准确的HCC编码对医疗机构来说是必要的，以便获得公平的补偿。Below are a few highlights to know about the CMS HCC model complexities and risk adjustment use:

• CMS requires an encounter each calendar year and diagnosis by an APRN, PA or physician.
• Documentation must be accurate and support the diagnosis.
• Some codes have RAF value. Some do not. Increased severity doesn’t usually increase risk adjustment factor (RAF).
• HCC codes are not always intuitive. Physicians may require decision support.
• HCC代码是可加性的，有些还带有乘数。
• Population complexity/severity affects payment in many Medicare contracts.
• RAF用于质量和安全的基准。
• RAF使患者管理的识别和分层成为可能。

The Impact of Appropriate HCC Coding

Even though the payment model is not intuitive, an organization’s ability to perform well within this model should increase over time. For example, in Figure 1 below, the table shows sample patient data from a 76-year-old female patient with an RAF score of .448. The two options show how different diagnoses change the patient’s risk score, and, as a result, the annual member payment.

In option one, the patient shows a diagnosis of obesity, which has an HCC Risk Score of zero. In option two, the patient shows a diagnosis of morbid obesity with a BMI of 42 and an HCC Risk Score of .273. Similarly, option one shows a diagnosis of asthma and an HCC Risk Score of zero. Option two shows a diagnosis of COPD and a risk score of .328. When a patient has a diagnosis of major depression, if left uncategorized, the diagnosis adds no value. If any category is chosen, such as “single episode” in the case of option two below, this adds a risk score of .395. The two different options show a patient of similar complexity but varying diagnoses, which results in vastly different annual member payments. Option one showed a total RAF score 1.029 and an annual Medical Advantage member payment of $9,000; Option two showed a RAF score of 3.633 and a Medicare Advantage member payment of $32,000 annually. While physicians should not change their diagnoses, it is important to code accurately and take credit, where deserved, for serving a complex population.

Driving Improvement Through Interdisciplinary Workgroups

The example above provides a compelling rationale for organizations to improve their HCC coding accuracy. However, the first step is obtaining accuratedata在试图改善这一领域之前。成立一个工作组来负责提高文献和HCC编码的准确性也可能是有益的。该工作组可以包括分析团队、问责医疗组织(ACO)团队、临床医生、诊所经理、运营和医疗编码人员。

Forming the workgroup can help oversee the following five key action items necessary for improving HCC coding accuracy:

1. Having an accurate problem list. Many healthcare organizations have been inputting data in an EMR for years now, resulting in lots of data, and most likely an inaccurate problem list. Ensuring an accurate problem list involves removing duplicative and inactive diagnoses, identifying key areas with discrete data in the EMR, and using a diagnosis preference list to include HCC suffix codes and RAF values as well as prioritize results.
2. Ensuring patients are seen in each calendar year. The first question to ask is, “Can you identify patients with chronic illnesses who have not been seen during the calendar year?” If, so, the next step is then do so, which may be easier said than done. One way to do this at a glance is to build a clinical dashboard hat provides a snapshot of both EMR and claims data that provides a complete picture of patients not yet seen in a calendar year. Once the workgroup can identify these patients, they can match them with both visit and HCC coding gaps. The workgroup should acquire information at the system, region, clinic, or provider level and review with clinic staff regularly (such as on a quarterly basis). One best practice is to frontload visits for these patients early in the year when clinics have capacity.
3. 改进决策支持和EMR优化。Although educating providers is necessary to improve HCC coding accuracy, it’s also important to build appropriate coding into the daily encounter workflow. Some potential strategies include having an ACO identifier flagged in the EMR, decision-support tools that can be activated for select populations, and HCC diagnosis alerts for past codes.
4. 普及教育和交流。因为这是新的工作，当然不是直观的，所以在这个过程中教育临床医生是很重要的。让临床医生明白的最大教育要点不是他们应该寻找什么样的分数，而是准确性的重要性。工作组可以教育临床医生特异性的临床和财务价值。他们还可以教育诊所工作人员关于患者管理和报告的工具和工作流程的细节，并且在系统层面，教育应该围绕适当的风险调整和影响量化的重要性，以证明资源分配和合规性。
5. 跟踪业绩并发现机会。The last, and perhaps most important key initiative of the workgroup is to track performance and identify future opportunities for improvement. Measuring results provides the workgroup with compelling data to bring to stakeholders that shows what improvements were made, such as an increase in average RAF score, improvement in key problem list diagnoses, decrease in the number of members without an annual visit, an increase in the percentage of persistent condition diagnoses resolved. Once the workgroup has data to bring to stakeholders, the next step is to identify future opportunities for further improvements. One place to look for these is by reviewing unresolved persistent conditions for specific populations.

Key Lessons

For organizations that are looking to embark on an effort to improve their HCC coding accuracy and risk adjustment, below are four valuable lessons learned:

• 没有数据，编码准确性机会的大小和存在不是很明显。
• Using data to focus efforts helped find topics that were practice and valuable to end users and improve engagement.
• 在遭遇战的上游和过程中使用EMR是易于管理和有效的。
• Clinic staff want reports to see how they are doing compared to peers.

Fair Reimbursement for Serving Complex Patient Populations

Although HCC coding accuracy and risk adjustment requires changes to the way healthcare organizations are documenting and coding chronic conditions, doing so can help the organization capture more complete diagnoses, resulting in higher and more appropriate reimbursement and improved care delivery for complex patient populations.

With increasing Medicare Advantage numbers, healthcare organizations need to improve coding accuracy to remain financially viable. Creating a workgroup that’s responsible for key action items is crucial to the success of this initiative. They can help ensure the organization has an accurate problem list, chronically ill patients are seen once per calendar year, improve decision-support and EMR optimization, educate clinicians and staff, and track performance of the initiatives to share with stakeholders. They can then look for further opportunities for improvement. If healthcare organizations appropriately document the complexity of their patients, they are eligible for greater CMS revenue that can then be reinvested to better meet the needs of their patient population.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. ACOs: Four Ways Technology Contributes to Success
2. Healthcare Data Management: Three Principles of Using Data to Its Full Potential
3. Why Clinical Quality Should Drive Healthcare Business Strategy
4. Linking Clinical and Financial Data: The Key to Real Quality and Cost Outcomes

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