The RCxRules Blog

How Smart Rules Can Help Close the Gap Between Clinical Documentation and Coding

HCC coding is a significant challenge for providers—even those who are already accustomed to thorough clinical documentation. As we discussed in our previous blog post, Medicare Advantage Organizations (MAOs) are very aware of the difficulties surrounding the coding process and often combat them with retrospective chart reviews. At RCxRules, we often see data that supports the idea that providers are doing a good job with clinical documentation but falling short with HCC coding. So why is coding such a challenge and what can medical groups do about it?

In many cases, the responsibility of capturing HCC codes falls to providers. While they may have support in the form of pre-visit planning, a prospective review, or other preparatory activities, providers are often missing coding opportunities. Providers did not attend medical school to become coders—it’s not what they do best, and its often not something they want to expend significant time and energy on.

Therefore, it’s not a surprise that we often see providers’ clinical documentation is better than their HCC coding. This is particularly true within certain specialties like cardiology and oncology. There are also specific HCC codes such as those for diabetes and morbid obesity where gaps can typically be found. Many of these scenarios require a coder’s expertise. For example, while a provider may capture diabetes without complication plus neuropathy within the clinical documentation, they may not know that this should actually be a combination HCC code:

Diabetes without complication (E11.9 - HCC 19) and Neuropathy (G58.9 – no HCC) can be combined to Diabetes with Neuropathy (E11.40 - HCC 18).

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Smart Rules: Clinical Documentation Improvement Software

Top-performing medical groups acknowledge that documentation is robust in many cases and that providers’ HCC coding is not always accurate, so they utilize an HCC coding review process. Because most groups have a small coding team, these groups focus their coders’ time on specific encounters.

Based on internal analysis and customer feedback, RCxRules created a set of Smart Rules to automatically present valuable encounters (those with a high probability that the clinical documentation is more robust than the HCC coding) to coders. You can download information on our Smart Rules here.

A 300+ multi-specialty physician group on the east coast enabled these Smart Rules, and within six weeks were able to add 295 HCC codes. The effort on their part was minimal—the technology automated and refined the review of encounters based on most frequent chronic conditions, so their coder would typically spend an hour per day reviewing these encounters. During that hour, they regularly added about 10 codes. The average monetary value of one HCC code is $4,830, so for this group that’s roughly an additional $1,424,850 in RAF value that was uncovered in under two months.

Implementing an HCC coding review process through the use of clinical documentation improvement software is a quick and cost-effective way to improve HCC coding capture. Set up a 1:1 meeting to learn more.

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