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Overcoming Common HCC Coding Challenges Part 2: Understanding Payer Feedback and Turning it Into Action

Overcoming Common HCC Coding Challenges Part 2: Understanding Payer Feedback and Turning it Into Action

Next up in this series of posts featuring case studies that demonstrate how top-performing medical groups overcame common HCC coding challenges is an independent medical group in the Midwest with over 150 providers. This multi-specialty organization participates in MSSP and Medicare Advantage and had just one HCC coder at their disposal to tackle this challenge.

The Challenge:

This group receives a lot of reports and information from their Medicare Advantage payers related to HCC coding opportunities, but they were struggling to understand the data and determine how to put it to use to improve HCC coding performance.

The Approach:

The organization decided to develop a better way to understand the breadth of payer data available to them and analyze it against their internal data for trends.


The Solution:

They began by meeting with the payer to get as much insight as possible into their data and recommendations. Then they collected HCC coding recapture data by provider, specialty, procedure, and HCC code from the past year using RCxRules reporting. With this information, they conducted an analysis of both payer and internal data sets to identify common themes.

In doing so, they discovered that many of the codes the payer was suggesting were codes commonly captured by their cardiologists. This led them to conduct a focused training for their six cardiologists to help these providers understand their role in HCC capture and how to improve documentation and coding. As a follow up, they sent weekly newsletters to these providers to reinforce education from the training.


Finally, they expanded their existing HCC coding concurrent review process to review encounters from cardiologists. Previously, the concurrent coding review was limited to just primary care providers.

The Outcome:

Within the first 3 months, the single HCC coder was able to review 370 cardiologist claims. In 12% of the claims that the coder reviewed, the documentation supported adding an ICD-10 code. This resulted in an increased RAF value of around $120k.*

If you missed part one of this series, make sure to check it out here: Overcoming Common HCC Coding Challenges Part 1: Limited Coder Staffing.

Set up a meeting to learn how RCxRules can help your organization overcome these challenges and more to improve your HCC coding accuracy and processes.


*Medical group’s share of increased RAF value is based on their payer contracts.

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