HCC Coding Impact On Patient Risk Scores

The concept of Hierarchical Condition Categories (HCC) is gaining momentum as many organizations shift to optimized care. Needless to say, it’s critical for organizations to have an in-depth understanding of risk-management coding to avoid any confusion or inappropriate reimbursement calculation. The vendors for HCC risk adjustment coding play a herculean role in leveraging the risk adjustment. It becomes critical to choose a professional and experienced partner to optimize the financial returns.

A Brief About HCC Coding

Hierarchical Condition Categories, or HCCs, are sets of medical codes designed explicitly for respective medical diagnoses. The Centers have used these for Medicare and Medicaid Services (CMS) for more than 20 years as an integral element of the risk adjustment process. It is an excellent aid in estimating the future risks and expected annual sum of the medical assistance. Each HCC pinpoints diagnoses with the same medical intricacies and similar estimated annual expenses.

The Use Of HCCs – How And By Whom?

HCCs are deployed in calculation of the monetary amount that a patient is liable to pay for the medical aid under the Medical Advantage insurance plans. The incharge adds HCCs to the clinical records of the patient besides other documentation required by CMS for the disbursement of financial medical aid. HCC coding relies on ICD-10-CM coding that aids in  assigning risk scores to the patients.

The professional coder uses HCC coding to review the medical records of the patient and abstracts the useful information and records concerned with the risk management payment model. The healthcare insurance plan vendors provide the respective coders.

Each HCC included in a payment model embeds a value called the Risk Adjustment Factor (RAF). This is further used by the CMS for commercial risk adjustment to evaluate the amount allotted to the health plans that cater to the healthcare needs of insurance seekers.

The Impact Of Professional HCC Coding On Patient Risk Scores

Risk adjustment aids in the estimation of accurate financial assistance to organizations that provide medical assistance to patients according to the criticality of their ailments. Professional HCC coding can affect patient risk scores as it is directly connected to risk adjustment. Let’s explore the benefits of a competent HCC coding -

 

1. Coding - It’s a risk adjustment model that adjusts the financial aid to the patient on the basis of their health status. It includes the identification of all the concerned diagnosis codes. These codes affect the patient risk scores and ensure that these are accurately recorded.
2. Assessment Of The Risk - The risk assessment services involve the identification of gaps in medical care, upgrade in patient outcomes, and record all the relevant data required for accurate reporting and documentation.
3. Compliance With Regulations - Professional vendors providing risk assessments are aware of the constant upgrades by the authorities, including CMS. They work in compliance with the rules and regulations.
4. Document Verification - Risk assessment services aid in the document review process and make sure that all the information is recorded correctly. They do the verification to eliminate the flaws, if any.

 

The Medical Conditions Represented By HCCs

It’s pretty self-explanatory that HCCs represent critical medical conditions that include an expensive treatment. CMS reclassified the clinical model, which led to expansion in HCC categories from 86 to 115. This also led to a change in the ICD-10-CM codes, which were earlier represented by ICD-9-CM. The significant conditions represented by top HCC categories include diabetes, pulmonary ailments, critical cardiac-related diseases, chronic depression, bipolar diseases, prostate cancer, and other critical disorders.

How HCCs Affect Reimbursements

HCCs are directly related to the financial aid provided to the patients under medical insurance. CMS directly refers to the records prepared by HCC coders. The patients undergoing critical medical aid usually have higher HCC records. The medical service providers who enroll these patients are reimbursed in higher amounts than the ones with patients with lower HCCs. The medical organizations that do not look after proper documentation of patients with chronic ailments miss out on appropriate financial aid by CMS. Hence, HCCs have a significant impact on the amount of reimbursement to be received by medical aid providers.

How To Perform A Seamless Risk Adjustment

Risk adjustment can be a complicated process that includes various challenges. From the above-mentioned information, it’s clear that risk adjustment can’t have any loops as it can lead to improper disbursement of insurance aid. Below are a few factors to execute an appropriate risk adjustment -

 

• Maintenance Of Accurate Records - It’s crucial for the clinical in charge to focus on the discreet and fledged maintenance of patient records. The data must be maintained consistently without any lags, as it can mess up the HCC records. This further leads to inaccurate documentation and improper allocation of funds.
• Professional Coders - An experienced HCC coder is a must for a reduction in risk. Avoid over-coding or under-coding as it may lead to investigations, fines, inappropriate funding against the insurance, and more.
• Competent Resources - The organization must be deployed with efficient resources for a proper risk assessment. Besides, there must be in-depth research and understanding to handle the risk adjustment professionally.
• Constant Upgrades - The regulator bodies for risk adjustment keep on changing the guidelines. Hence, it’s critical to keep aligned with the continuous upgrades and comply with the rules and regulations to avoid any consequences.

Conclusion

With an efficient risk assessment, patient care techniques and compensation can be significantly enhanced. Otherwise, risk management is a complex process, but it can be made easy with the aid of a professional service provider. The use of advanced technology and various AI tools can significantly improve things. Unlock your full potential by using an appropriate risk assessment and improve your revenue generation.