The RCxRules Blog

HCC Coding: An Effective Offense Starts with a Solid Defense

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Most of us have heard the sporting maxim that “defense wins championships.” Why? Because a good defense not only manages (and helps minimize) potential losses—it also leverages an efficient offense.

The same is true in risk adjustment: if you want to build a high-functioning value-based organization, implementing a defensive approach is crucial.

Let’s take a closer look at both of these aspects of an effective HCC coding strategy.


Offensive measures are valuable—but insufficient on their own.

In risk adjustment, an offensive approach most often means giving the physician time and education to accurately document and add HCC codes.

As valuable as that is—and it is a key element of an effective strategy—it’s important to remember that doctors are medical professionals. They aren’t coding professionals—and never will be. They’ll always care more about the clinical aspects of their jobs—and the health of their patients—more than they’ll ever care about the intricacies of HCC coding. (And isn’t that what you want when you’re the patient?) Even when they’re not caring for patients, they need to spend significant time keeping up with the latest advances in their own branches of medicine, most of which are constantly changing and evolving.

By all means, give your physicians the training they need to do their part in meeting the requirements of value-based reimbursement schemes. Just don’t expect them to ever do it perfectly—or take the place of professional coding specialists.

Over the last several years, buzz words such as artificial intelligence and natural language processing have echoed across the value-based care and reimbursement landscape. These technologies—which primarily focus on uncovering net new HCC codes—can also be a worthwhile addition to your offensive arsenal as long as the new HCC codes are supported by appropriate medical record documentation. But beware of the risk of false positives—and compliance concerns—when the added HCCs far outweigh the deleted ones.


Defense: the foundation of an effective value-based reimbursement strategy.

When it comes to risk management strategy, defense means making sure that through systematic and ongoing assurance and review procedures, only defendable HCC codes are submitted to your payers.

Good defense—and the objective balance between adding and deleting HCC codes—has become increasingly important for those provider organizations that are bearing additional risk, especially as the number of plans and payers increase.

The reviews that lead to both adding and deleting HCC codes primarily occur at two points during the HCC coding process:


HCC Coding Best Practices


Retrospective review

A retrospective review occurs after the initial claim has been submitted to the payer.

When reviews take place only retrospectively, they often identify HCC codes that are supported by medical record documentation but were not originally reported, in addition to HCC codes that should not have been submitted in the first place because they fail to meet documentation guidelines. Unfortunately, by that time the incorrect codes have already been sent to the payer, leading to administrative overhead and inefficiencies (because claims with the corrected codes must now be resubmitted) and creating false positives for gaps and recapture statistics.


Concurrent review

A better approach is to have certified risk coders (CRCs) review value-based encounters for HCC accuracy before claim submission—a process referred to as concurrent review.

During concurrent reviews, coders proactively address all HCC codes supported by documentation in the EMR before incorrect codes can get to the payer.  Very importantly, this includes both adding missing HCC codes that are supported by the documentation and removing HCC codes that are not.  This streamlines the entire process, improves efficiency, and helps reduce statistical inaccuracies.

Whether your organization participates in a Medicare ACO—and bears the entirety of an audit risk—or is involved in plans where the health plan takes the brunt of the audit risk, a defensive approach that focuses on ensuring defendable, appropriate, and accurate HCCs before claim submission makes for a winning strategy. Once that’s in place, any offensive measures you take are likely to be more effective because they’re supported by a solid foundation.

Remember that when you’re putting together or updating your organization’s game plans.

Learn how one organization successfully operates in a value-based world. Watch our on-demand webinar now "HCC Coding: 3 Steps for Operational Success."

For more in-depth information on tackling and taking control of the HCC capture process, watch our on-demand webinar—HCC Coding: 3 Steps to Operational Success—today. And learn how Signature Healthcare, an award-winning medical group, successfully adjusted their workflow to meet the demands of value-based contracts.



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