A Comprehensive Guide on HCC Coding Reviews


In the ever-evolving landscape of medical coding, Hierarchical Condition Category (HCC) coding has emerged as a critical component in accurately capturing and reporting diagnosis codes and it plays a pivotal role in risk adjustment, reimbursement optimization, and overall healthcare quality improvement.

There are 3 types of HCC Coding reviews. Let's talk about each one to understand their impact on clinical documentation and the practices.

Prospective Reviews:

Prospective review is conducted to prepare physicians for upcoming face-to-face encounters. Certified HCC risk coders evaluate HCC coding history, prescriptions, hospital records, lab results, radiology reports, and physician notes to identify inaccurately captured HCC conditions. Physicians update the EHR problem list or discuss in morning huddles to prepare for appointments. During the encounter, physicians document and capture HCC codes if supported by the patient's examination.

Some healthcare providers use RAF Score to analyze individual ICDs from current and past claims, prioritizing high-value charts for prospective review. Accurate revenue impact analysis can only be provided by tools that analyze each ICD and their interactions. After the review, certified risk coders assess the billed, missed, and new diagnosis codes, and re-run revenue impact analysis. Without proper tools, revenue impact analysis can be daunting. Sharing the report with physicians containing HCC conditions not properly captured provides solid supporting evidence for seeking physician's additional effort for Clinical Document Improvement.

  • Optimal Capture and Reporting of Diagnosis Codes:

    Improving documentation practices is paramount in prospective reviews. Healthcare providers should aim to capture and report diagnosis codes with increased attention to detail. This includes documenting key elements such as the severity of the condition, laterality, specific details of the diagnosis, cause-and-effect relationships, and the current status of the condition. By providing comprehensive and specific documentation, HCC coding can be more accurate, leading to improved risk adjustment and appropriate reimbursement for the services rendered.
  • Identifying Missed Opportunities:

    In prospective reviews, it is essential to identify instances where risk-adjusted diagnoses are not adequately documented and reported, despite the healthcare provider actively treating the condition. These missed opportunities can lead to underestimation of risk adjustment factor scores, resulting in potential under-reimbursement for the services provided. Identifying such gaps in documentation allows healthcare providers to rectify the oversight and optimize risk adjustment factor scores, ensuring fair compensation for the care reimbursed.

Retrospective Reviews:

Retrospective review takes place after a patient receives care, and claims are submitted to the health insurance company. These reviews often reveal missed HCC codes supported by documentation that were not reported earlier, as well as HCC codes that were inaccurately reported due to a lack of documentation. In addition to it, during the chart review, some ICD codes may be modified to improve specificity and reflect the cause-and-effect relationship. The main objective of retrospective review is to analyze medical records and HCC coding data retrospectively in order to correct any inaccuracies or omissions.

  • Correct HCC Coding Initiatives:

    Retrospective reviews often uncover instances where provider-billed diagnoses are modified or deleted due to missing documentation or failure to meet the MEAT (Monitor, Evaluate, Assess & Treat) criteria. These reviews allow coders to rectify errors and ensure that all documented conditions are appropriately reported. In addition to it, retrospective reviews may reveal the need to add new diagnosis codes for documented conditions that were previously overlooked during HCC coding.
  • Validating Coding Accuracy:

    By reviewing medical records, medical coders can validate the accuracy of HCC coding. This process ensures that the reported diagnoses align with the documented clinical indicators. Any discrepancies found can be corrected through appropriate HCC coding adjustments, which leads to improved reimbursement accuracy.

Concurrent Reviews:

Concurrent reviews involve coders checking clinical documentation and HCC codes in Electronic Medical Records (EMR) in real-time before submitting claims to health insurance companies. This process ensures accurate diagnosis coding that aligns with the physician's documentation in the EMR. While physicians may provide comprehensive clinical documentation, they might not always select the most appropriate ICD-10 code. By having the HCC coding team conduct this concurrent review before claim submission, two benefits are achieved. Firstly, it accurately translates the physician's efforts in delivering and documenting care into precise HCC codes. Secondly, it ensures the correct HCC codes are present on the initial claim, avoiding the need for additional retrospective reviews.

  • Real-time Query Opportunities:

    Concurrent reviews offer the advantage of identifying immediate query opportunities based on clinical indicators. This enables coding specialists to seek clarification from healthcare providers promptly, leading to improved documentation and accurate coding. Real-time query opportunities ensure that no potential HCC coding is overlooked.
  • Enhancing Documentation Practices:

    Continuous concurrent reviews provide valuable insights into documentation practices. Feedback from coders during the patient's care can help healthcare providers understand the importance of comprehensive documentation, ultimately leading to improved coding accuracy and risk adjustment scores.

In conclusion, HCC coding is a vital aspect of the healthcare industry, for risk adjustment, reimbursement, and quality improvement. Prospective, retrospective, and concurrent reviews are HCC coding processes for enhancing clinical documentation and coding practices. By identifying areas for improvement and optimizing HCC coding accuracy, healthcare providers and medical coding companies in the USA can ensure fair reimbursement and deliver high-quality care to patients. Embracing the objectives of each review type will undoubtedly unlock the true potential of HCC coding and drive positive changes in the healthcare landscape.

RAF score calculation and revenue impact analysis should be integral part of these HCC coding reviews. There are several types of tools available for prospective, retrospective, and concurrent reviews, but there are no right tools that can help in doing revenue impact analysis, to help choosing the right high value charts and decide if the chart should be re-submitted after the review. You can sign up for them and easily incorporate them into your daily operations.

Explore these tools on the NPI Data Services website, the leading healthcare IT Company in the USA to learn more: https://www.npidataservices.com