Hierarchical condition categories are gaining momentum under risk adjustment.
We are entering more risk-based contracts that require us to submit hierarchical condition category (HCC) codes. We’re familiar with HCCs from our Medicare Advantage (MA) plans, but we need to up our game with commercial health plans. What is a logical next step?
Answer: You have already taken a logical next step—expanding your knowledge about HCCs. Greater familiarity with the HCC framework helps organizations receive optimal payment under risk adjustment and value-based payment. To advance your HCC program even further, I suggest three practical steps: proactive audits, physician collaboration, and technology enablement.
Conduct proactive audits. HCCs are the means for ensuring appropriate MA plan payment by calculation of risk-adjustment factor (RAF) risk scores. As you mentioned, many commercial health plans are beginning to use RAF scores to more accurately predict and control the cost of care.
HCCs must be captured each year for every patient covered under the plan. Individuals with serious or chronic illnesses are assigned higher risk factors and risk-adjustment scores. When documentation and proper HCC code assignment go unchecked, organizations risk leaving significant revenue on the table. Conversely, organizations may experience revenue recoupment from the Centers for Medicare and Medicaid Services (CMS) due to HCC overcoding. Proactive audits of HCC coding and RAF scores can mitigate these risks.
Reviews are performed retrospectively by payers, but also can be accomplished internally by providers as proactive measures to ensure accuracy and integrity of risk adjustment data and MA risk-adjusted payments. These audits should identify gaps in care, incomplete documentation, and incorrect codes.
Drive greater physician collaboration. Physicians are integral stakeholders in healthcare organizations’ quests for HCC accuracy. Physicians must document four essential components for proper HCC assignment and annually update findings for patients covered under health plans:
- Proper ICD-10 diagnosis code on claims
- Supporting documentation for all submitted diagnoses, including severity and stage of chronic conditions
- Six mandatory items in the supporting documentation, as defined by CMS
- Evidence of face-to-face evaluations each calendar year
Ensuring that all risk-adjustment patients are seen on an annual basis is crucial. Physicians should perform a mid-year check to guarantee patients are included. Any patients without validated treatment plans, including active conditions documented and coded, should be contacted. Proactive outreach avoids pushing for visits at the end of the year.
Consider technology enablement. Technology plays an important role in guaranteeing that plan patients are seen annually. Systems can prospectively track patients and ensure required information is collected and verified during visits. By incorporating technology into HCC strategies, healthcare organizations streamline processes, reduce physician administrative burdens, and increase the likelihood of proper payment.
Cathy Brownfield, MsHI, RHIA, CCS, is a founder and COO, TrustHCS.