#icd-10 coding services

Affordable and Accurate Medical Coding Services in the USA

High reimbursement can be obtained only when HCC coding is accurate and there is proper documentation to capture the complexity of patient’s condition. Risk adjustment and HCC coding (Hierarchal Condition Category) model was mandated by the CMS in 1997. Today, the payment model plays a crucial role in insurance benefits and reimbursement scenario. Under this model, a risk factor score is assigned to individuals who have been diagnosed with a chronic or serious illness based on demographics or health conditions.

Risk Adjustment Model

HCC coding success is hugely dependent on how accurately and timely data is captured. It also depends on the proper tracking of a patient’s care and condition over a certain period of time.

How it works?

Health conditions of a patient are determined by ICD-10 diagnose that is submitted on claims by the physician. Based on the complexity of the patient’s condition, HCC codes allow payments to be risk-adjusted. Future financial utilization and risk is predicted by the risk adjustment model using a patient’s documented 12- month diagnostic coding history.

As per the risk adjustment model, demographics and diagnoses of a patient are used for determining a risk score. This is a relative measure of how costly that patient is being anticipated to be. For instance, a healthy patient will have a below-average Risk Adjustment Factor (RAF) score which means, revenue from the insurance premium is transferred from health patients to patients who have an above-average RAF score.

If chart documentation is incomplete or inadequate or if there is inaccurate diagnosis coding, then it will lead to lower risk score. Proper coding increases risk adjustment factor (RAF) scores and also helps improve the revenue flow of the practice.

When it comes to the risk adjustment model, payment rate of two patients in the same practice can differ. There are several factors on which this is based, determining the amount of work/risk involved in maintaining the patient’s health.

It is very important to ensure proper HCC capture and proper claims submission with codes that capture all manifestations of a chronic disease that a patient has. Since ICD-10 has increased code specificity along with requirements for detailed documentation, proper HCC capture has become vital.

Many practices are choosing to outsource HCC coding needs to a third party because it is helping them get timely revenue. They are also able to focus on quality care provision rather than worry about coding.  

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The main source of data is the hospital and physician claims and these drive the risk adjustment model. For best risk adjustment, it is very important to ensure specificity and accuracy in medical documentation and even subsequent ICD-10 coding. HCCs determine reimbursement on the basis of patients’ diagnosis.

CMS uses the HCC (Hierarchal Condition Category) risk adjustment model for estimating the predicted costs for Medicare beneficiaries. The results have a direct impact on the revenue received by healthcare organizations for patients who are enrolled in Medicare Advantage Plan. In order to be successful in risk-based contracts, it is necessary for healthcare organizations to ensure accuracy in clinical documentation. The documentation must reflect clinical needs and diagnoses of patients and must have the necessary specificity for patient assignment to correct RAF score. Accuracy in documentation plays a huge role in helping the provider receive appropriate and timely reimbursement.

If there is failure to properly assign risk to patients, it will impact reimbursement, potentially resulting in unfair compensation for the healthcare provided to the patient. Providers also face reduced payment in a performance-based payment model if medical documentation lacks accuracy needed for assigning the accurate diagnosis codes.

Coding guidelines prohibit the assumption of cause and effect relationships to a large extent. If the relationship isn’t well documented, it will become impossible to report it. At times, providers end up overlooking the chronic conditions. They don’t document chronic and/or permanent diagnoses as often as they are assessed or treated. CMS needs these diagnoses to be submitted at least on an annual basis for risk adjustment.

It is very important for providers to educate, monitor ad evaluate the quality of outpatient documentation and coding in their practice in order to mitigate risks.

To support an HCC, it is very important to have accurate clinical documentation in the patient’s heath record that will support the presence of the condition. It should also indicate the qualified provider’s assessment or plan for management of the condition.

There are several strategies that are used by organizations for reviewing clinical documentation. For instance, some organizations use the MEAT approach that stands for monitoring, evaluation, assessment and treatment.

Many healthcare organizations choose to outsource HCC coding services to a third party. Considering the complexities, it is helpful to let a third party handle this task because it helps in obtaining timely reimbursement.

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