3 Ways to Improve HCC Capture for Value-Based Payments

May 9, 2017 by Antonio Arias, MBA, CHBME

Topics: Meaningful Use Stage 2, Practice Management, Medical Billing Company

To capitalize on value-based payment opportunities, medical practices and other healthcare groups must underpin their medical billing and coding efforts with strong policies and processes that comply with VBR (aka ‘value-based reimbursement’) expectations.

HCC capture is one of those expectations. Including the correct hierarchical condition category (HCC) diagnoses on encounter claims is essential to the success of value-based payment initiatives. With the correct HCCs, your patients can be appropriately risk-adjusted (in the eyes of payers) to meet most VBR program requirements.

While that may sound simple enough, but there are several common reasons why HCC diagnoses can go missing on encounter claims:

  1. Clinical fail to document the HCC-linked diagnoses for their patients
  2. Clinicians document a patient’s relevant conditions, but do not code for the conditions
  3. Patients fail to come in for a visit during the required time period, so there is no opportunity to capture relevant diagnoses

To rectify the issues on the above list and themselves up for success with VBR long-term, practices should take the following three efforts.

Engage in Staff Education & Awareness

If your medical billing service, clinical staff, and administrative team members aren’t cognizant of your HCC efforts, they can’t help you achieve successful capture measures. Engage in role-appropriate training, then activate your staff to take action toward improvement.

For example, task an employee with reviewing a list of patients with undocumented HCC diagnoses to identify the patients who do not have scheduled visits for the remainder of the year. Why? Because those patients can be scheduled for an appropriate office visit to help with HCC tracking and risk profiling for your practice.

Revisit Retrospective Coding

Providers always capture detailed diagnosis information for their patients in visit notes, but they may not include documented diagnoses in the final claims for visits when they enter their own billing codes, If diagnoses are not in the claim, they are not counted towards that patient’s annual HCC total.

Audit your processes to see if that’s happening at your practice. You need accurate coding processes in place across inpatient to outpatient and office settings to establish a comprehensive process that captures complete HCC considerations.

You should also lay out all associated tasks and responsibilities of the engagement in a contract or binding agreement, including:

Conduct Data Analysis & Establish Controls

Auditing your process should be your first toward putting stronger analytical HCC measures in place. Evaluate your current-state success. Are physicians routinely capturing complete HCC-relevant diagnosis information? How much risk information do you have on your patient base? Where do you have gaps?

From there, see if your technology solutions can help you out. Diagnosis guidance provided within the provider's EHR workflow can serve as a reference as they evaluate, document and bill for each patient visit—a safeguard to help providers capture the HCC-linked diagnoses for each patient.


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