The RCxRules Blog

HCCs and RAF Scores: A Two-Part Challenge

doctor stressed about HCC coding

Medical groups throughout the country continue to make great strides in improving their clinical quality and documentation under value-based programs. Yet many find that their RAF scores still fail to meet their expectations.

They know their scores do not reflect the true health of their patients, which leaves them wondering: why is this happening?

While HCC coding is complex, let’s focus on two key components of HCC coding and your RAF scores:


1. Clinically Addressing the HCC

This challenge has been a focus for many medical groups, and most are doing a great job and making progress as they invest in provider support activities such as clinical documentation initiatives (CDI), education, pre-visit planning, and care coordination.

These efforts are critical to success under value-based care programs. But by themselves they do not lead directly to improvements in RAF scores.


2. Coding the HCC

Once physicians address a patient’s health status and include documentation in the EMR, their attention turns to HCC coding. While doctors play an integral role in HCC coding, expecting them to be proficient coders on top of everything else they’re required to do as medical professionals is a tall order.

The sheer number of Dx and HCC codes contributes to this challenge. To put it in perspective, there are 9,700+ Dx codes that map to an HCC—and 429 of them apply to diabetes alone!

As medical groups see their physicians struggle with coding—and miss HCC codes that have been accurately documented in the EMR—they begin to appreciate the difference between fully documenting a patient’s HCC conditions in the EMR and accurately capturing the correct HCC codes on the claim.


So what’s the answer?

For RAF scores to accurately reflect each patient’s health status, physicians need the help of coders and technology to ensure that HCC coding complexities are taken into account before a claim is sent to the payer.

Our progressive customers have solved this gap by implementing an HCC coding review process that incorporates our HCC Coding Software. This adds a quality assurance (QA) layer to ensure accurate RAF scores, leveraging physicians’ documentation and treatment of patients by automatically reviewing value-based claims in real time before submission to payers. In a recent example of the difference this can make, one customer recaptured 261 missing HCC codes within a month of implementing our HCC coding software, greatly impacting their overall RAF average.

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