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Risk Adjustment Impacts Everyone: 10 Tips for Improving your HCC Coding and Billing

by | May 17, 2021

As a healthcare consultant, one of the most frequent questions I get from physicians and practices is: “How does Hierarchical Condition Category (HCC) coding affect me?” Traditionally, risk adjustment and its related HCC coding have been most associated with Medicare Advantage plans – yet it is quickly making inroads in other areas of healthcare, such as Medicaid and Commercial plans. This means that HCC coding is affecting everyone more – and that physicians and practices of all kinds should look for ways to improve their HCC coding and billing procedures. 

 How HCC Coding Works

In a very broad sense, HCC is a coding system used to determine a patient’s estimated costs to the system, to aid with risk adjustment for possible future health issues. The Medicare HCC risk adjustment model is value-based, compensating health plans for the care given to each one of its membersPrecise and accurate coding in the practice paints a picture and creates a summary of the disease burden of each one of your patients. That summary is then on display for CMS, who determines the compensation the health plan receives for the patients you take care of.  

This system allows the proper resources to go to the most medically needy patients. In turn, many health plans also reimburse providers for complete and accurate documentation, given their critical role in risk adjustment. These providers play a critical role in risk adjustment, making it important to be at the top of your game for both coding and documentation. For both primary care and specialists, this means accurate and specific coding and documenting is a top priority – to accurately portray the complexity of care each patient receives. This involves using ICD-10 codes to the highest specificity and supporting your selection of codes with your documentation.  

Luckily, there are best practices every physician and practice can follow to improve their risk adjustment performance.  

10 Top Tips for Improving Your HCC Billing and Coding 

  1. Document and code all conditions that exist at the time of the encounter.  
  2. Include any condition(s) that affect the care or management of the patient’s needs. This includes conditions that are managed by a specialist but affects your decision-making – e.g., diabetes, atrial fibrillation, COPD, multiple sclerosis, hemiplegia, rheumatoid arthritis, Parkinson’s disease, and more. 
  3. Code all conditions to the highest specificity. You may need to defer to specialists diagnosis, since they may have a better understanding of the disease process for the specific condition they are monitoring. 
  4. Be suspicious of unspecified codes, since there is usually an opportunity to utilize a code that will more accurately describe a condition – ultimately resulting in improved reimbursement. 
  5. Document and code all complications and comorbidities, and use linking terms such as “because of,” “related to” or “associated with”. Coding guidelines prohibit the assumption of cause-and-effect relationships. If the relationship is not documented clearly, you cannot report it. 
  6. Keep the problem list up to date with current dates. Delete conditions that no longer exist.  
  7. Documentation must support the presence of your diagnosis codes and indicate your assessment and plan for the management of each code. This may be as simple as using words such as “stable, continue medications,” “managed by oncology, or “diet and exercised discussed”.  
  8. For each coded condition include at least one component of MEAT (monitor, evaluate, assess, treat) in your assessment and plan. 
  9. Do not forget common status codes (permanent conditions) such as amputations, transplant status, ostomies, etc. 
  10. Watch for conflicting documentation. Your HPI notes need to support the ICD-10 codes that you choose (e.g., HPI states “no diabetic complications,” but ICD-10 E11.42 code “Diabetes type II with polyneuropathy” is used). 

Since HCC coding is directly linked to payment from CMS, it is imperative to paint the picture of each patient in your practice with accurate and specific ICD-10 codes, along with thorough documentation for proper reimbursement. The focus in valuebased care shifts from submitting codes for reimbursement to submitting codes to support the care you are delivering to each member of the health plan.  

Medical Advantage Can Help  

Here at Medical Advantage, we recognize the stakes of HCC coding in today’s value-based market and understand the importance of making the most of the interdependent relationship between health plans and physicians. We work hard to achieve results and improve both reimbursements and patient outcomes – talk to one of our consultants today about how we can help you simplify the delivery of healthcare by building a bridge between practices and health plans. 

Talk to a Billing & RCM Consultant Today

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