The RCxRules Blog

3 Varieties of HCC Coding Review: Prospective, Concurrent, and Retrospective

prospective concurrent and retrospective review

Coding reviews are essential for financial success in value-based contracts. But what kind—or kinds—of reviews work best?

Read on for a quick overview of the three main HCC review processes, their pros and cons, and the optimum approach for most organizations.


Prospective Review

A prospective coding review process is intended to help physicians prepare for upcoming patient encounters. 

Reviewers—who are often certified risk coders—evaluate the patient’s HCC code history, prescription drugs, hospital records, lab results, and physician notes. They may also leverage access to out-of-network claims, which helps establish a 360° view of available clinical information.

As coders review the medical record, they identify patients with likely HCC conditions whose diagnosis codes have not been captured accurately.  Once the HCC opportunity has been identified, the next step is to prepare the physicians to address the condition(s) at the upcoming appointment.  This communication is often performed via updates to the EHR problem list or delivered to the physician ahead of the patient’s visit via a morning huddle or similar type of meeting.

The physician must then ensure that the noted conditions are documented and included in the encounter as appropriate.  If the physician’s examination of the patient supports the HCC condition, he or she will then document and capture the HCC code(s) during the encounter.  Employing staff members, who assist with pre-visit planning, significantly improves the process and reduces the burden put on the physician.


Concurrent Review

In a concurrent coding review process, coders review the EHR/medical notes and HCC codes in real time before the claims are submitted to payers. In many cases, coders will leverage existing EHR and RCM technology to enable this type of review. (Note: most organizations leverage claim scrubbers or similar technology to review fee-for-service claims before they are submitted to payers.)

This process helps ensure the diagnosis coding accurately supports what the physician documented in the EMR.   In many cases, the physician will perform robust clinical documentation but may not select the most appropriate ICD-10 code.  Having the medical coding team perform this concurrent review prior to claim submission achieves two benefits. First, it ensures the physician's hard work in delivering and documenting care is correctly translated into accurate HCC codes. Second, it ensures the payers have the correct HCC codes on the initial claim, eliminating the need for an additional retrospective review.

Concurrent review works best in tandem with other initiatives such as prospective review and physician education.

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Retrospective Review

Retrospective coding review occurs after care has been delivered and claims have been submitted to the payer.  Such reviews often uncover HCC codes supported by the medical record that were not reported, as well as HCC codes that should not have been submitted because they did not meet documentation guidelines.

Because the retrospective approach reviews charts later rather than in real time, clinical documentation issues identified are likely to be longstanding ones. It also requires a secondary process to flag the charts and send the corrected HCC coding information to the payer. This process is often used with Medicare Advantage programs, which have a relatively straightforward method for submitting retrospective coding adjustments known as the Alternate Submission Method (ASM). This process becomes more difficult in ACOs and CPC+ programs where submitting retrospective coding adjustments is cumbersome.


What works best?

For the Medicare Shared Savings Program (MSSP) as well as Medicare Advantage, using a combination of prospective and concurrent reviews may seem overwhelming at first glance, but it’s the smoothest, least disruptive way to go—and it's likely to yield the greatest operational and financial benefits relative to costs.

That’s because each stage reduces the time and cost required for the following one. Properly implemented prospective reviews significantly increase the likelihood that your physicians will get the documentation right the first time—which decreases back and forth communications, corrections, and do-overs during the concurrent stage. And detailed concurrent reviews can reduce or eliminate the need for retrospective reviews.

It should be noted that while retrospective reviews do remain a workable option for Medicare Advantage programs because of their ASM process, this model is changing.  CMS is moving towards the Encounter Data Submission (EDS) method for HCC coding, which is pressuring groups to include the correct diagnosis codes on the initial claim.

Regardless of your organization’s focus and specialties—and no matter what value-based programs you participate in—implementing at least one of these HCC coding review processes will help ensure that you receive correct compensation for the care your organization provides.

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.

The HCC Coding- Improve RAF Score Accuracy and Boost Staff Efficiency. Learn More.


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