One of the significant developments that have impacted Medicare Advantage (MA) plans during the past decade is HCC (Hierarchical Condition Categories) coding. Medicare has used the HCC coding model to calculate payments to health care providers and insurance plans since 2004. Physicians treating patients enrolled in MA plans need to pay attention to optimizing their coding in this area in order to maximize practice revenue.
Challenges of HCC Risk Adjustment Coding
The Centers for Medicare & Medicaid Services (CMS) uses the HCC Risk Adjustment Coding methodology to adjust MA health plan payments based on the risk of the beneficiaries they enroll. The basis of this methodology is that patients’ health conditions differ, with some having more serious conditions. CMS pays MA plans for the health expenditure risk of their enrollees. Therefore,
- assignment of the diagnostic codes (ICD-10) determine the risk scores
- assigned risk scores determine the reimbursements to the MA plans
A patient can be assigned more than one HCC. Some common chronic conditions found in Medicare beneficiaries which MA plans look for include Diabetes without Complications, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Breast Cancer, Ischemic Heart Disease, and Angina.
For physicians, accurate and timely documentation of diagnosis and focus on tracking a patient’s care and condition over time is necessary to maximize Medicare payments. The HCC must be documented every 12 months for CMS to reimburse the MA plan. In fact, if the codes are not captured within this time period, it will result in a revenue gap for the MA plan. Documentation of chronic stable conditions is crucial. If new patients already have assigned HCCs from a previous health plan, physicians should maintain those (as appropriate). This will support continuity of care and comprehensive data collection.
To manage this challenging long-term strategy effectively and maintain accurate documentation, many providers rely on a professional medical coding company.
How Professional Medical Coding Services Help
Established medical coding companies have dedicated AAPC-certified coders who are experts in HCC coding and are well-positioned to help physicians improve their risk scores. Their support covers:
- Detailed and accurate chart analysis and review
- HCC diagnosis coding to the highest degree of specificity
- Extracting and verifying all HCC codes in patient charts through RADV audit for accurate risk assessment
- Identifying documentation errors
- Reporting of missed/embedded/suspect codes
- Submission of complete and accurate data before CMS deadlines
With the right HCC coding service provider, physicians can improve patient care as well as avoid the risk of reduced payments from CMS. Reliable medical coding companies offer competitively priced solutions as well as a free trial of their HCC Risk Adjustment Coding services.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.