The RCxRules Blog

3 Ways to Prioritize HCC Coding Review Opportunities in the New Year

The start of a new year brings with it a new set of challenges for Population Health Managers. All previously captured HCC codes are now potential missed opportunities that need to be recaptured. So, how do top Population Health Managers set their groups up for success?

Most top-performing groups already have effective clinical processes in place (i.e., chart prep and pre-visit planning) and are ready to delve into the next layer of analysis and execution for stronger HCC coding capture and more accurate RAF scores. To help ensure complete HCC coding capture and risk adjustment success, we’ve identified the coding review priorities these groups are focusing on right now.

Setting Up for Success

Top-performing groups often structure their HCC coding strategies around the four main due dates associated with the CMS schedule of initial, mid-year, final, and interim final risk score runs. These are good milestone dates at which to reassess current HCC coding capture progress and determine any next steps needed to stay on track.

Increased Coder Productivity

Before creating an HCC coding strategy and aligning it with the risk run dates, groups need to determine what can be realistically accomplished to ensure the most complete and accurate HCC coding capture. They’ll need to consider prospective, concurrent, and retrospective efforts in the context of their unique situation and the resources they have available. Some important items for consideration include the number of value-based contracts, priority of value-based contracts based on risk level, number of patients, number of providers, current population health staff (such as care coordinators and HCC coders), and the technology available.

Most leading Population Health Managers find it most cost-effective and efficient to focus on prospective and concurrent processes, such as chart prep and charge review. Retrospective review can be costly and time consuming. For most groups, it’s not realistic to prepare every provider for every patient visit, and then conduct a post-visit review of all provider documentation.

To help prioritize, leading groups filter their data by payer, visit type, provider specialty, and patient complexity to determine which encounters have the potential to be the highest yielding from a risk adjustment standpoint. Based on our experience working with Next Generation ACOs and other top performing groups, we’ve consistently seen them prioritize their HCC coding review efforts around these three instances:

1. Payer

Top groups focus on those encounters related to the payer or contract that have the most at-risk dollars at stake. At RCxRules, many of our customers focus initially on their Medicare Advantage contracts. In many cases, a targeted coder review enables coders to add or modify HCCs on one out of every four encounters. The average monetary RAF value of one HCC is $4,830 (based on $10,000 per member per year), so if you multiply $4,830 by 25% of your total ACO member count, you’ll have a big impact on the gross value incurred to help you care for those members.

2. Visit Type

Next, these groups focus on Annual Wellness Visits (AWVs) and certain visit types (for example appointments with Level 4 E&M codes). These are important visits as they tend to be longer and more in depth, allowing providers to gather more details about a patient’s health status and document them in the medical record. Medical groups with a solid chart review process tend to do well in capturing HCC codes during AWVs at the point of care since they’re well-prepared ahead of the visit.

At RCxRules, we see the most opportunity in Level 4 visits during coding reviews or audits—after the patient has been seen, but before the claim is sent to the payer. Typically, the provider has sufficient documentation, but the coding could be improved. Monitoring and collecting data from these Level 4 visits to determine which HCCs could be added or deleted during coding review is a great way to identify trends and opportunities for provider education. If groups have the capacity to expand their efforts, a good next step is to focus on Level 3 visits.


3. Provider and Specialty

Additionally, top groups home in on specific providers or specialties that could most effectively move the needle to recapture those codes. In other words, those specialties where the documentation in the medical record is typically better than the coding indicates. Diabetes and morbid obesity are two of the most common—and commonly missed—HCCs.

Maximizing Impact

To maximize patient visits, top Population Health Managers prepare providers ahead of key patient visits by providing them with a simple and clean list of HCC coding opportunities. For more information on this, see The 7 HCC Coding Review Opportunities You Don't Want to Miss.

After patient visits, leading groups may hold encounters that are determined to be a high priority in their system for longer to conduct a more thorough review of the HCC codes included before claims are sent to payers. This is done for two reasons. The first is that extra time spent reviewing up front is more cost-effective and efficient than doing a retrospective review. Second, there’s no guarantee of another face-to-face opportunity with that patient, especially in light of COVID-19.

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COVID-19 makes maximizing face-to-face patient visits that much more important, as care has been—and most likely will continue to be—deferred. It’s estimated the reduction in patient visits could lead to a 3% - 7% reduction in risk scores and payments in 2021.1

“Where did heart attacks go in 2020? People didn’t stop having them. It is clear that Americans are deferring care across the board. People with mild chest pain would normally go to the hospital for an EKG, and end up on therapy that slows disease progression. Instead, these people are not engaging in care and there will be morbidity and mortality impacts because of it.” - Dave Meyer, Vice President, STARS, Cigna and a member of the RISE Advisory Board and Risk Adjustment Policy Committee.

RCxRules Can Help

As we’ve outlined above, the start of a new year can be overwhelming when it comes to HCC coding—there are so many opportunities it can be difficult to determine where to start. By prioritizing capture efforts and maximizing capture opportunities, you can make this seemingly impossible endeavor become possible—and RCxRules can help.

RCxRules works with you to filter your value-based visits and encounters based on specific criteria, such as payers, annual wellness visits or in-person visits, diagnosis codes, locations, specialties, and more. Then, based on your capacity, we help you prioritize and determine what your coder’s focus should be.

RCxRules is a scalable and cost-effective tool to take your value-based care initiatives to the next level. Set up a 1:1 meeting to learn more.


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1 https://avalere.com/insights/how-covid-19-could-reduce-ma-risk-scores-and-payments-in-2021

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