The RCxRules Blog

The 7 HCC Coding Review Opportunities You Don't Want to Miss

HCC coding review is a complicated process, and it’s easy for coding opportunities to slip through the cracks. When patient diagnoses aren't fully captured, a gap forms between the realities of patient care needs and the RAF scores that determine the funds allocated to care for these patients.

To identify more HCC Coding opportunities in a concurrent coding review process (before claims are sent to payers), it is important to understand the common gaps that exist—and how to prioritize capturing them.

We recommend starting with these seven common HCC coding opportunities:

1. Annual Recapture

Also known as revalidation codes, dropped codes, and refresh codes, recapture opportunities identify patients with one or more historical HCCs and ensure those HCCs are captured again in the calendar year. For example, a patient with an amputation needs that condition to be documented and coded anew each year.

2. Highest Level of Specificity

In addition to capturing all diagnoses, it’s important to also code them to the highest level of specificity. More specific diagnoses translate to higher RAF value (i.e. higher dollar allocation to manage patient care). Specificity gaps are commonly found in diagnoses such as, diabetes, chronic kidney disease, or depression. For example, many groups review the documented codes for unspecified type 1 (E10.9) and type 2 (E11.9) diabetes to ensure the diagnosis is coded to the highest level of specificity.

3. Missing Code

In certain cases, ICD-10 guidelines require an additional code to be billed with existing codes. For example, the hypertensive heart and 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.

4. Combination Code

A combination code is a code where two codes can be combined into a single code that has a higher RAF value. As an example, diabetes (E11.9 - HCC 19) and neuropathy (G58.9 – no HCC value) can be combined into a single code (E11.40 -HCC 18) which has a higher RAF value.




5. Quality/HEDIS Measures

This opportunity focuses on closing quality and HEDIS measure gaps. For example, a patient coded for hypertension (I10) often requires blood pressure monitoring, so it would be important to review these encounters, and if appropriate, add the blood pressure monitoring CPT II code 2000F.

6. Newly Attributed Patients

To ensure accurate fund allocation for new patients, it’s important that they have a face-to-face visit in the current year. It is also important to ensure their visits are documented and coded appropriately.

7. Suspect Code

If certain assessments, results, or medications are documented for a patient, the condition(s) identified and/or treated in many cases relate to an ICD-10 code. For example, if a patient is on diabetes medication, the coder can verify the documentation and add the diabetes code if it is missing.

How Does RCxRules Help You Identify These HCC Coding Opportunities and Close HCC Gaps?

The RCxRules technology automates the review of all value-based encounters in real time before they go to the payer. With RCxRules, you can start small with a single or part-time coder. Our team works with you to configure RCxRules to focus on specific criteria, such as certain payers, annual wellness visits or in-person visits, diagnosis codes, locations, specialties, etc., so the number of tasks sent to your coder does not overwhelm them.

If RCxRules detects an HCC coding opportunity, such as the ones indicated above, the technology will task a coder to review the documentation and correct the coding on the encounter if supported. This exception-based workflow makes RCxRules a scalable and cost-effective approach to take your value-based care initiatives to the next level.

To understand return on investment, RCxRules reporting showcases the number of codes added and removed, along with the subsequent RAF value of each HCC.

Schedule a 1:1 meeting to start identifying more HCC coding opportunities to close more and more HCC coding gaps today.


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