Understanding The Importance Of HCC Coding In Today’s World

The concept of Hierarchical Condition Category (HCCs) has been there for quite a long time, it is not exactly a brand-new concept, however, many organizations are now understanding the importance of value-based care which brings HCC Coding into the picture. With a strong base of HCCs, it would become a liability for the healthcare systems. 

What Is HCC Coding?

What is HCC Coding?

Hierarchical Condition Category also abbreviated as HCC refers to those medical codes that are connected to several particular diagnoses. Since the beginning of 2004, the use of HCC Coding has been widely used by various different centers for Medicare and Medicaid Services. It has been majorly seen being a part of the risk-adjustment model that helps in the identification of patients with chronic or acute health conditions. Henceforth, this lets Medicare scheme the costs for the near future along with the expected risk.

Each of the Hierarchical Conditions Category epitomizes diagnoses that have the same clinical convolution along with the surmised yearly care costs. Medical coding services and solutions know the importance of HCC coding. HCCs are widely used by healthcare institutions in order to calculate the total payment for all of their patients who are insured under the Affordable Care Act (ACA), Accountable Care Organizations (ACOs), Medicare Advantage (MA) plans, or much more. Medical practitioners make use of HCC in their patient’s medical records paired with the correct documentation. 

Types Of Conditions That Are Represented by HCC Codes

Hierarchical Conditions Category represents acute, chronic, or severe health conditions that tend to be quite costly. As of the year 2020, it was seen that there are a total of 86 HCC codes neatly arranged into several different categories. All of these codes comprise 9700 ICD-10 codes, each of which represents different medical conditions.

The topmost HCC categories tend to comprise major mental disorders such as bipolar disorders or depression, diabetes, pulmonary disease and asthma, congestive heart failure, heart arrhythmias, prostate, and breast cancer along with rheumatoid arthritis.

What Is The Risk Adjustment Factor And How Is It Related To HCC?

Hierarchical condition categories solution

Risk Adjustment Factor, often abbreviated as the RAF score refers to the approximate cost of any patient’s care that is based upon their demographic information along with the burden of the disease they have been diagnosed with. The RAF is also used while calculating the payments of the medical institutions.

Each HCC is therefore associated with the individual’s comparative factor which then leads to a calculation of an average along with the HCC Coding factors including the demographic score. The result is therefore multiplied with a prearranged amount of dollars that help in the setting up of the PMPM (per-member-per-month) reimbursement. The PMPM, therefore, refers to the amount of payment a certain medical provider tends to receive for any individual who has been previously enrolled in a Medicare Advantage (MA) plan despite all of the medical services that have been provided. 

Healthier individuals tend to have a less than average RAF while patients with chronic or acute illnesses tend to have a high RAF which thereby impacts the amount that must be paid. Medical professionals thoroughly report upon the diagnosis for each of the patient. RAF cannot be always determined from the patient’s medical history or previous test results; a face-to-face encounter is a must. 

When medical professionals want to accomplish the process of proper medical documentation for each of their patients, it is important to understand MEAT. The acronym stands for;

  1. Monitoring signs and symptoms of the disease.

  2. Evaluating the test results along with the medicines given and the response of the patient to the treatment.

  3. Addressing or assessing the tests, reviewing records, educating the patient and also providing necessary counselling to the patient party and the patient itself.

  4. Treating the patient with therapies, medicines.

Understanding The Importance of HCC When It Comes to Reimbursements

The role of HCC is quite widespread when it comes to the medical industry. Not only does it pay a crucial role in the amount received by several different healthcare institutes but also it helps in determining which patient has a higher or a lower HCC. This calculation forms the basis upon which the intensity of the medical treatment is figured out.

Medical professionals who enroll the high-risk patients get reimbursements of higher value than when compared to the lower-risk patients. If medical organizations miss out on documenting the HCC codes they will not get reimbursed in a proper manner. In order to receive the entire amount, it is of utmost importance to mention the specific nuances for each of the patients.

What Are the Benefits Of The HCC Coding Engine?

The HCC Coding Engine works simultaneously during the process of review. The HCC Coding software is engineered in such a way that it ensures that the process of coding goes out during the initial claims process. The workflow that exists in the organization is amalgamated with the HCC Coding tool. This allows for the clinical encounters to get processed thoroughly with the help of rules engines as it is moved from EMR right to the process of revenue cycle. 

The HCC Coding accuracy follows an approach based on the rules. The software makes use of filtering logic which thereby prioritizes and targets encounters containing the highest of values. This allows the billing and coding team to increase the impact and efficiency of their work flow. As a matter of fact, billers and coders tend to act on the 30% to 40% out of all the encounters that is identified during the process of HCC Coding. Once the changes are made by the coder, it gets integrated in a proper manner in the revenue cycle management system.

The strong set of rules that are included with the HCC Coding Engine proves to be of utmost importance since it helps to identify certain issues of coding without any hassle. The solutions identify these coding issue which do not have a direct link with the process of clinical documentation but is rather linked with the insurance payer’s ICD-10 guidelines.

RCM or Revenue Cycle Management is a key part of today’s healthcare industry, and if you are looking to outsource your company’s medical billing, Synergy HCLS can be a great service provider.