The original meaning of low-hanging fruit refers to the sweet, easy-to-reach fruit at the lower end of a tree's branches. For obvious reasons, workers appreciate the ease with which this fruit can be picked, in contrast to the effort required to reach the fruit found higher in the tree. Although it may seem implausible, there is low-hanging fruit in value-based reimbursement–HCC code recapture.
HCC code recapture refers to updating a patient’s HCC codes during the current calendar year, based on the knowledge of what was captured/submitted to a payer in the previous calendar year. This good work (capturing correct HCC codes) yields an important benefit–more accurate/appropriate HCC codes leads to higher Risk Adjustment Factor (RAF) scores and higher reimbursement rates/bonus pool dollars.
Since a patient’s HCC codes are ultimately driven off the underlying clinical documentation in the EHR, it may seem obvious that providers would update the clinical notes and recapture relevant HCC codes when the patient returns for a visit the following year. However, data supports that this is not occurring in the real world.
Physicians have plenty of challenges managing their high patient loads and ensuring robust clinical documentation has been entered in the EHR. To expect physicians to also be knowledgeable and fluent in the intricacies of HCC coding is likely too much to ask. Across multiple practices in multiple states around the country, we are seeing data that shows, on average, physicians are recapturing only 40% of the HCC codes that were captured the previous year. A low number that is costing your physicians and your organization money.
To solve the problem of low HCC code recapture there are three questions to consider:
1. Who is responsible for performing the HCC coding work?
For many organizations (particularly those who have invested in big EHR/RCM systems), the overwhelming focus is to push diagnosis coding data into the EHR to empower physicians to be better coders. Along those lines, there is a belief that the improved data will transform physicians into coders. This is an unrealistic expectation as physicians want to practice medicine. What physicians can contribute is robust documentation to support the inclusion of HCC codes. However, the work of translating documentation into medical coding is work that should be performed by an HCC coder, ideally before the claim is sent to the payer.
2. How is the HCC coding review work completed?
Assuming your organization has the resources to help physicians with HCC coding, a key question is: how is that work being performed? Throwing people at problems is a recurring theme in healthcare. There is a reason healthcare occupations are projected to grow by 18% from 2016-2026 according to a Bureau of Labor Statistics analysis. For many groups the “state-of-the-art” today is to employ a team of coders to manually review all value-based claims and identify HCC codes eligible for recapture, a laborious task akin to finding a needle in a haystack.
3. Where in the workflow is the HCC coding work being done?
If there is an HCC review process in place, it is usually occurring after the claim has been submitted to the payer. If a missing HCC code is identified through this process, the recourse is to submit a supplemental claim or complete the cumbersome process of deleting the original charge and re-posting the corrected transaction into the practice management system–not an ideal workflow.
There is a more efficient process to master HCC code recapture. Educate your physicians on becoming experts in documentation (not coding) and employ software to sort through your value-based claims and present targeted HCC code recapture opportunities to your HCC coders. Sound easy enough?
If the government or your medicare advantage payers are going to extend a low-hanging branch, are you prepared to pick that sweet, easy-to-reach fruit?
