Best Practices for HCC Code Review and Audit

This year has brought a new set of challenges for health managers. All of the previously collected CMS HCC codes have now potentially missed the chances and just need to be recaptured. So, how do the best health managers set the groups up for success?

However, most of the high-performing groups already have adequate clinical processes functioning and are ready to reach the next layer of the execution and analysis for a more accurate RAF score and efficient CMS HCC code capture. Here we have identified the coding review priorities the group is focusing on.

Understand HCC Coding Guidelines

Before conducting a risk coding analysis or audit, it is essential to understand the HCC code guidelines. The Centers for Medicare and Medicaid Services (CMS) provides detailed guidelines for HCC coding, including the types of diagnoses that are included in each HCC category.

It is important to understand the HCC categories and the code that is used to assign them, as well as the documentation requirements for each HCC category in order to properly assess the level of risk associated with the coding. A proper understanding of HCC coding guidelines can assist in reducing the risk coding errors and potential audit findings.

Develop a Comprehensive Audit Plan

A comprehensive risk coding audit plan is essential for ensuring that all areas of HCC coding are covered during the audit process. The audit plan should include a review of medical records, provider documentation, and coding practices with a focus on potential areas of risk associated with coding errors.

The audit plan should also include a review of the provider’s policies and procedures for HCC coding, as well as staff training and education on HCC coding to identify and address any gaps in knowledge that may increase the risk of coding errors. By incorporating risk coding analysis into the audit plan, potential audit findings can be reduced, and the overall accuracy and completeness of HCC coding can be improved.

Conduct a Thorough Code Review

During the risk coding review process, it is important to not only review all diagnosis codes assigned to the patient for accuracy and support in the medical record but also assess potential areas of risk associated with coding errors. It is important to ensure that the HCC categories assigned to the patient are appropriate based on the diagnosis codes and medical record documentation, as inaccurately assigned HCC code categories can lead to under or overpayment, as well as potential audit findings. Incorporating risk coding analysis can assist in identifying potential areas of risk and improving the overall accuracy and completeness of HCC coding.

Review Provider Documentation

Provider documentation is critical for accurate CMS HCC coding. During the audit process, it is important to review provider documentation to ensure that it supports the diagnosis codes and HCC categories assigned to the patient. Providers should be encouraged to document all relevant diagnoses and conditions to ensure that accurate HCC coding can be assigned.

Monitor Coding Trends

Monitoring risk coding trends over time can help identify potential areas of risk associated with coding errors and highlight areas where coding practices may need to be improved. By analyzing coding trends, healthcare organizations can identify potential coding errors and inconsistencies, as well as areas where staff training and education may be necessary to reduce the likelihood of coding errors.

Utilizing risk coding analysis in the monitoring of coding trends can assist in identifying potential areas of risk, reducing audit findings, and improving overall coding accuracy and completeness.

Conduct Staff Training and Education

Staff training and education are essential for accurate CMS HCC. All staff involved in the coding and billing process should be trained on HCC coding guidelines and best practices. It is important to provide ongoing education and training to ensure that staff members are up-to-date on any changes to HCC coding guidelines.

Implement Quality Assurance Processes

Implementing risk coding quality assurance processes can help identify potential areas of risk associated with coding errors and ensure that coding practices are consistent across the organization. Quality assurance processes can include periodic audits with a focus on potential areas of risk, ongoing monitoring of coding practices for accuracy and completeness, and feedback to staff on areas where improvement is needed.

Incorporating risk coding analysis into quality assurance processes can assist in identifying potential areas of risk, reducing the likelihood of coding errors, and improving overall coding accuracy and completeness.

Conclusion

HCC coding is an essential part of healthcare coding and billing, and accurate coding is important for both patients and healthcare organizations. A thorough CMS HCC review and audit process can help identify areas where coding practices can be improved and ensure that accurate HCC coding is assigned. By following these best practices, healthcare organizations can improve the accuracy of their HCC coding practices and ensure that they receive appropriate reimbursement for their services.