Patients enrolled in risk-adjusted payment models such as Medicare Advantage are assigned a Risk Adjustment Factor (RAF) score. This score measures how costly a patient is predicted to be for the current year and predicts future costs associated with their health conditions.
The RAF is based on diagnostic data, claims, and medical records collected from doctors’ offices, hospitals, and outpatient clinics. This model is complex and requires a lot of work.
Accurately Captured Patient Information
For healthcare providers to be reimbursed based on their patient’s health status, they need to accurately document and report ICD-10-CM codes. Risk-adjustment models use this information to determine a patient’s health status and RAF score.
The RAF score adds the individual risk factors together to calculate each patient’s total health status score. This is a significant factor in determining the value of Medicare Advantage payments to physicians and other providers.
However, many healthcare organizations need help identifying their patients’ HCC-related diagnosis codes annually to meet this requirement. This process is time-consuming and can cause significant clerical backlogs in their administrative processes.
Whether it is an inpatient or outpatient encounter, thorough documentation of a patient’s health status is key to accurate risk adjustment coding and reimbursement. This includes in-visit notes and a detailed list of all diagnosis codes and comorbid conditions treated during the visit.
The risk adjustment HCC coding and clinical documentation may seem time-consuming and challenging. Still, it’s important to keep in mind that these records give a precise and comprehensive picture of the patient’s health condition, which in turn aids payers in determining a patient’s risk-adjustment factor (RAF) score and payment for their care.
Detailed In-Visit Notes
In-visit notes are important to document a patient’s condition. They should include details such as diagnosis, treatment, and medication so that providers can accurately document patient data for billing and reimbursement purposes. However, many physicians need to record this information in their documentation. This can create a problem when capturing HCC and RAF scores for these patients.
Hierarchical Condition Categories (HCCs) are a set of medical codes used by CMS to calculate risk-adjusted payments for Medicare Advantage and other payers based on the complexity of a specific diagnosis. These diagnoses represent costly chronic health conditions and some serious acute conditions.
HCCs use ICD-10-CM codes to identify diseases and similar conditions that have increased costs for Medicare. They are arranged into 86 disease categories and include a variety of symptoms and body systems.
For example, some of the top HCC groups include cancer, diabetes, COPD, heart failure, kidney disease, and substance use disorder. These groups are grouped into eight specific tiers of severity.
Each of these tiers contributes to the RAF score of a patient. As a result, the more complex a patient’s condition is, the higher their RAF score will be.
Organizations should invest in adequate staff training to help ensure the correct coding is performed for these complex diagnoses. This includes ensuring that all physicians, coders, and office staff understand the importance of detailed in-visit notes and HCCs for their patients’ RAF scores.
A comprehensive coding process is essential for HCC coding, regardless of the type of organization. Having an accurate problem list, using EHR and claim data to identify potential cases for HCC capture, and clearly understanding how to document the RAF score properly will allow an organization to receive full reimbursement from their payers.
Accurate Documentation of Chronic Conditions
Accurate documentation of all chronic conditions is crucial to risk adjustment HCC coding. These conditions and their comorbidities are vital in determining healthcare outcomes and costs as the healthcare landscape moves toward value-based care.
The Hierarchical Condition Category (HCC) coding payment model uses ICD-10-CM code mapping to assign risk scores to patients based on their diagnosis and health status. Insurance companies use RAF (risk adjustment factor) scores to forecast and measure the cost and quality of care for Medicare Advantage beneficiaries.
These RAF scores are calculated using a patient’s medical history and diagnosis to predict their cost and utilization for the current year. Various factors can affect RAF scores, including age, gender, and comorbidities.
One way to improve the quality of clinical documentation is by providing training and education for physicians about how to document their patients’ chronic conditions for risk adjustment purposes. This includes understanding the MEAT acronym and making sure all documentation reflects the complexity of a patient’s disease.
Once the documentation has been improved, routine audits are required to ensure all conditions have been reported accurately. This involves examining problem lists, identifying duplicate or inactive diagnoses, removing them from the EMR, and verifying that HCC suffix codes and RAF values are properly reported.
Routine Audits
A well-planned and executed audit will help identify documentation issues that could lead to improper coding or payment. As part of this process, the auditor may conduct interviews with employees, and flowcharts of processes will be prepared to better understand the controls in place.
In addition to these review areas, the auditor should also focus on any research charts, consents, and regulatory documents that must be reviewed for accuracy. This will ensure that all documents are complete and can be provided to the audit team. A room appropriately equipped with computers, internet access, a fax machine, and a telephone should be reserved for the audit.
It’s also important to remember that physician documentation should always be focused on the purpose of the audit; it is still imperative that healthcare organizations accurately capture patient health status for reimbursement and quality purposes.
While there are many ways to perform a comprehensive HCC audit, the most effective approach is to use an established and pre-tested template. This will help reduce the time required for the audit and minimize any disruption to normal business operations.
During this process, the auditing team will conduct interviews with employees, and flowcharts will be prepared to understand each area’s controls better.
