Advantages of HCC Risk Adjustment Coding

In place of conventional medical coding, using HCC risk adjustment coding can help you increase income and guarantee that your patients receive the care they require. The best way to ensure your practice can use HCC risk adjustment coding effectively is to partner with a certified medical coder.

CMS-HCC risk adjustment coding

Using Hierarchical Condition Categories (HCCs) in the CMS risk adjustment model is a critical way for healthcare organizations to improve patient care, reduce costs and improve reimbursement. HCCs are also becoming more prevalent in value-based payment models. HCC risk adjustment coding helps healthcare organizations optimize their data and analytics, leading to higher quality care and better reimbursement for complex patient populations.

CMS uses hierarchical Condition Categories to calculate the estimated care costs for Medicare Advantage beneficiaries. These numbers are then applied to a capitated rate for members. HCCs have proven successful in predicting resource use by Medicare Advantage enrollees.

Nineteen 79 HCC categories correspond to nine thousand ICD-10-CM diagnosis codes. Each of these categories has its relative factor. Next, these factors are weighted to assign higher values to more severe conditions. Finally, these factors are added together to determine the overall risk score.

The Centers for Medicare and Medicaid Services (CMS) developed the Hierarchical Condition Category (HCC) risk adjustment model to pay Medicare Advantage Organizations (MAOs) differently based on disease burden. The model was initially implemented in 2004. The model has since become widely used as value-based payment models have gained popularity.

CMS uses diagnosis information from medical records to calculate risk scores. Next, healthcare providers must list the chronic ailments of each patient. These diagnoses will impact clinical, prescription drugs, and long-term healthcare costs.

Changing the way you document and code chronic conditions

Changing how you document and code your patients can make or break your bottom line. A well-documented medical record enables your staff to provide an accurate and timely diagnosis and treatment plan. It can also help weed out duds and streamline your billing process. A robust system such as MDCodePro will prove invaluable in keeping your practice on the right track. It also helps you to better document your patients’ visits.

A good rule of thumb is to document and code your patients’ conditions once or twice a year. Then, the coding staff can decide which needs to record and which to omit. For example, an outpatient surgery should be coded as first listed but may not be performed if the patient has diabetes or is on blood thinners. The same rule of thumb should be applied to chronic conditions. The best way to do this is to provide a detailed list of patient conditions to your staff at the beginning of each year. It will help ensure accurate reporting and billing every time.

The top-of-the-line coding and billing system should be configured to include the following: a patient-specific, personalized list of conditions; an in-house medical coding and billing system; a dedicated phone and email line for each staff member; and a policy of omitting the recording of non-existent patient conditions.

Relying on code recapture alone

There may be more efficient ways to go than using code recapture alone for HCC risk adjustment. There are several software solutions out there that can present a targeted set of opportunities.

However, these programs are performing only for some. Many organizations have teams of coders who perform manual reviews of value-based claims. The process can be tedious and time-consuming. A well-trained team will improve the quality of your healthcare by reducing errors and identifying opportunities for improvement.

The HCC risk adjustment program uses risk values to calculate a numeric score for each enrollee. This score is called the RAF or risk adjustment factor. A score ranging from one to four will be assigned to an enrollee based on their medical record data submitted for reimbursement in the year the claim was submitted.

The RAF measures a member’s risk of incurring medical costs associated with a specific condition. The RAF is not intended to replace a health care plan’s usual and customary benefits but to supplement it.

The RAF may not be for everyone, but using it correctly can increase your bottom line. It is also the best way to identify which members may benefit most from a specific benefit, so you can better serve them.

Partnering with a certified medical coder

Increasing pressures on healthcare organizations to improve revenue performance require an investment in highly skilled certified professional coders. A Certified Medical Coder is an invaluable resource for health plans and provider organizations to ensure accurate documentation of clinical conditions.

Medical coders work for many healthcare organizations, including physician offices, mental health clinics, ambulatory surgery centers, and imaging centers. They must comprehensively understand electronic medical records and the claims process. They are also well-compensated for their expertise and knowledge.

Many commercial payers use the HCC (Hierarchical Condition Category) risk adjustment model to determine a patient’s health risk. This method relies on ICD-10 coding to identify patient health conditions. Then, the values of each HCC are added together to create an overall risk score.

Physicians need to ensure that all of the relevant codings are captured. It is an essential step in providing appropriate reimbursement for providers.

Several commercial payers, including Medicare Advantage plans and Medicare, use the HCC risk adjustment model. It is a fairly straightforward method to use. However, it’s essential to know the specific coding requirements for each HCC.

A certified medical coder can help you ensure that all relevant coding is included in the HCC. They will review your medical records and verify that all coded services are accurate. They will also conduct on-site validation audits and provide feedback on discrepancies.


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