Massachusetts Hospital Increases HCC Recapture for More Accurate Risk Adjustment

The Challenge

A non-profit hospital in Massachusetts began their shift to value-based reimbursement with new payer contracts, including Medicare Advantage and Managed Medicaid. To successfully manage these contracts, the hospital needed to invest in population health and ensure proper risk adjustment through accurate HCC Coding, while also maintaining the efficiency of their fee-for-service operations.

The health system’s physicians, who had always known that patients with chronic conditions or multiple ailments require more time and attention, quickly grasped the concepts of value-based reimbursement and risk adjustment. But ensuring that providers appropriately coded these patient encounters, which is essential to determining patients’ HCC scores, and ultimately the hospital’s reimbursement, proved more challenging.

The primary focus of any physician is providing the best care for their patients, and the hospital’s providers were no exception. To support them, the hospital needed to implement a new cost-effective internal process with additional resources to perform administrative work as quickly and accurately as possible.

The Strategy

The hospital’s strategic focus included three elements:

  1. Prepare physicians for complex HCC patient visits before entering the exam room
  2. Have coding experts review HCC patient encounters pre-claim to ensure correct coding
  3. Assess each physician’s HCC recapture rate to determine their impact on overall financials

The goal: maximize the time physicians could spend on patient care while ensuring precise, clear clinical documentation and accurate HCC coding.

The Solution

By leveraging RCxRules software to automate the identification of HCC patients requiring pre-visit and pre-claim review, the health system could shift more of its resources to those patients and encounters needing extra attention. By targeting high value HCC patients, the hospital was able to make this process as efficient as possible.

For example, providers treating patients with acute forms of diabetes would often enter a generic ICD-10 diabetes code on those encounters, simply out of habit or familiarity with that diagnosis code.

To address such situations, RCxRules’ sophisticated rules engine:

  • Automatically reviews every encounter that is finalized in the EMR
  • Identifies those for which a more accurate and specific diagnosis code is likely warranted
  • Uses workflow automation to send such encounters to a coder for review and final determination of coding


Following a six-month pilot to incorporate RCxRules software into their workflow and evaluate its impact, the hospital found that it had:

  • Increased HCC recapture by 15% within 60 days
  • Identified $750,000 in HCC recapture opportunity* 
  • Gained actionable, real-time data to improve physician HCC coding performance

* Based on $9,500 annual cost per patient and the CMS HCC coding values

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