As the healthcare industry shifts from fee-for-service to value-based care, revenue cycle and coding teams must adapt their processes and technologies to keep up. Claim scrubbers are a proven technology that work to help medical groups ensure their fee-for-service claims meet various requirements. But do they measure up in a value-based care context?
The requirements that revenue cycle and coding teams need to meet are changing as Medicare Advantage and other programs that use risk adjustment (like MSSP, Managed Medicaid, and Commercial ACOs) gain traction.1 As the industry moves towards value-based care and risk-based contracts, many revenue cycle and coding teams now must ensure their providers’ coding is accurate and compliant (i.e., supported by documentation).
“In a fall survey conducted by Premier, we learned that 40 percent of health system CFOs now believe that moving toward value-based care is a core strategy for future financial viability.” -Health Affairs
There are a variety of claim scrubber products on the market to help these teams, from basic to more advanced offerings. Basic claim scrubbers are entirely managed by the vendor and deliver a limited set of rules—most often they simply deliver industry-standard rules, such as CCI, LCD, NCD, RVU, and MUE. More advanced claim scrubbers cover the basics listed above, and give users more flexibility and autonomy. They may offer features such as customer-specific rules, an interface for medical groups to create their own custom rules, specialty-specific rules, and/or rules that can look at historical data.
While the benefits and features above suffice for fee-for-service contracts, they fall short with value-based care contracts that utilize HCC coding (or risk adjustment) methodology. For a claim scrubber to support value-based care contracts, more robust functionality in the form of additional rule sets is needed.
The HCC coding rule set incorporates the CMS HCC coding methodology, including diagnosis code mapping, categories, and hierarchies. It also offers more detailed and flexible filtering and allows for enhanced use of historical diagnosis coding data. This rule set can help catch common HCC coding opportunities, such as:
- Annual recapture (i.e., revalidation codes, dropped codes, refresh codes). These opportunities identify patients with one or more historical HCCs that were not captured in the current calendar year.
- Highest level of specificity (i.e., unspecified diabetes – E10.9, E11.9). All diagnoses should be coded to the highest level of specificity. More specific diagnoses translate to higher RAF value.
- Missing Code. In certain cases, ICD-10 guidelines require an additional code to be billed with existing codes. For example, the hypertensive heart & CKD with heart failure (I13.0) code should also include a code to identify the specific type of heart failure, as well as a code to identify the stage of chronic kidney disease.
- Combination Code. This is a code where two codes can be combined into a single code that has a higher RAF value.
The HCC coding rule set also helps measure the value your coders and the HCC coding rules deliver with reports that measure the monetary value of the HCC codes that were added and deleted.
There has been a lot of improvement with automated claim scrubber technology when it comes to the growth of value-based reimbursement. The added responsibility of HCC code review, on top of ICD-10, CPT codes, and other administrative payer requirements, increases the complexity of an already complex process, but having the right technology in place can help. RCxRules is a modern solution that can identify and task all the standard fee-for-service billing rules as well as HCC coding opportunities.
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