Provider Education in HCC Risk Adjustment

Hierarchical Condition Category (HCC) risk adjustment depends on accurate documentation at the point of care. All conditions, including manifestations, complications and comorbidities, must be documented to the highest level of specificity to paint an accurate picture of a patient’s complexity. Subtle nuances involved in coding and documentation have a significant impact on risk adjustment factor (RAF) score accuracy, which in turn affects reimbursement and ultimately appropriateness of care for patients.

The responsibility for capturing the specificity required falls mostly on physicians’ shoulders - coders can’t include appropriate diagnosis codes on the claim without clear and complete documentation from the physician, nor can they assume a connection between conditions listed in the medical record if the provider has not explicitly spelled out the link in the documentation. Given this particularly significant role of precise provider documentation and coding in risk adjustment arrangements, investing in provider education is one of the most important steps healthcare organizations can take towards achieving success.

HCC risk adjustment is not a simple concept. Learning which code to use in the right situations takes time and effort, and physicians are often overwhelmed by the reporting requirements. The rules are also are constantly changing - diagnosis codes are added and removed each year and knowledge can quickly become outdated. But when physicians understand how risk-based contracts work, and the importance of HCC coding, they’re more likely to invest the extra time needed to properly and fully document each patient’s health status according to best practices.

Any provider education initiative should include these core principles:

- An overview of how the HCC method classifies ICD-10-CM codes into diagnostic groups and how coefficients are rolled up into RAF scores.

- Emphasis on the importance of proper coding and the impact of specificity to ensure that the true complexity of every patient is reflected in the coding and documentation.

- A focus on the most common conditions that physicians are more likely to encounter on a regular basis rather than covering all categories at once.

- In depth training regarding diagnosis-specific criteria for common and particularly complicated conditions that are prone to coding errors, such as diabetes and obesity.

- A plan to keep providers and support staff up-to-date on rule changes on a regular basis through a workgroup, series of refresher courses or peer-to-peer coaching sessions. Ideally a physician’s champion should be established to ensure leadership buy-in and the continuity of the program.

Organizations that implement a program covering at least the key aspects outlined above will be well positioned for success in HCC risk adjustment arrangements.