Risk Adjustment Coding

As the healthcare industry continues to shift towards value-based reimbursement, accurately capturing patient conditions through risk adjustment coding has never been more important to estimate future healthcare outcomes and cost. While there are many variables, including demographic characteristics and health status, to calculate the risk of a patient population, the primary factor to consider are the patient’s diagnosis codes. The resulting score reflects how much a provider should spend on taking care of their patients in a year. Without accurate data capture, the supporting diagnosis coding would be inaccurate, which can impact healthcare services, outcomes, and reimbursement.

As one of the leading risk adjustment coding companies, 3Gen Consulting offers comprehensive risk adjustment documentation and coding services by promoting precise clinical documentation and supporting it with accurate diagnosis coding. Our risk adjustment coding solutions are designed to provide a complete picture of a patient’s health to develop better care plans, improve outcomes, reduce costs, and receive optimal reimbursement.

Risk Adjustment Reviews

HCC Medical Coding

The Hierarchical Condition Category (HCC) Coding Model is an advanced risk-adjustment model designed to better estimate future health care costs for patients. The HCC risk adjustment model assigns a risk score, also called the Risk Adjustment Factor (RAF), to each eligible beneficiary, which is based on the beneficiary’s health condition as well as demographic characteristics such as age,gender, institutional status, etc. This model groups clinically related diagnosis codes on resource use, meaning that the higher the risk score, the higher the anticipated cost.

It is important to note that while for billing purposes, the diagnosis codes selected are to identify the reason for a visit or treatment; for risk adjustment purposes, all diagnosis for all current conditions must be captured without regard to current treatment and must be supported by documentation. This is where we, as an HCC coding company, can help! Our HCC risk adjustment coders will ensure documentation is complete, assign appropriate diagnosis codes if the conditions meet the TAMPER (treatment, assessment, monitor/medicate, plan, evaluate, or referral) or MEAT (monitor, evaluate, assess, or treat) criteria and ensure health plans, Accountable Care Organizations (ACOs), and providers are compensated accurately and are providing the highest level of care.

Risk Adjustment Reviews

Our certified risk adjustment coders have the experience and expertise to conduct risk-adjustment reviews prospectively (before a patient is seen), concurrently (before a claim is billed) and/or retrospectively (after a claim is billed).

Prospective Risk Adjustment

Reviewers play an important role in evaluating all available patient information, including previously documented HCC codes, prescription drugs, hospital records, lab results and physician notes. They are often certified risk coders who analyze these pieces of diagnostic information to ensure accuracy in coding, assess the level of risk associated with each patient’s health and ultimately give the provider a list of potential HCC diagnosis codes to consider during the encounter. Not only does this assessment help providers prepare treatment plans to address the identified conditions in an upcoming scheduled appointment, but it also helps payers predict costs for the following year using information from a base year. It is essential to have accurate data to accurately calculate premiums and reimbursements.

Concurrent Risk Adjustment

In a concurrent coding review process, our certified risk adjustment coders review the medical record and HCC codes in real time before the claims are submitted to payers. This helps ensure that claims are accurate, complete, and compliant with regulations before they are sent out. The use of concurrent coding reviews is not only to help reduce coding errors by catching them before claims submissions, but also to predict future costs using current year information. Additionally, it ensures that providers get paid for services rendered more quickly as there is less time spent troubleshooting incorrect or incomplete claims.

Retrospective Risk Adjustments

Retrospective coding review is an important part of the claims process for healthcare providers. It is conducted after care has been provided and claims have been submitted to the payer. This review helps to ensure that accurate and appropriate HCC documentation and codes were used in the claim submission process. Retrospective coding reviews are essential to not only identify if there were any HCC codes that were not reported despite documentation, but also to identify if HCC codes were reported despite not having supporting documentation. This process therefore identifies coding gaps and areas of improvement in practice operations and billing procedures, which can reduce costs and increase accuracy in the future.

Risk Adjustment Coding Challenges

To ensure that risk scores are accurately reflected at the member and population levels, it is critical to understand and have access to the various data elements for precise risk adjustment documentation & coding.

To calculate beneficiaries’ risk score, the risk adjustment model factors in several classification levels to map National Drug Codes (NDCs) up to HHS Drug Classes (RXCs). It is crucial to bill the precise number of NDC units for the corresponding HCPCS/CPT codes on your claims to enable more accurate payments and better drug cost management based on what was administered and billed.

Due to the nuances associated with risk adjustment documentation and coding, many organizations need to invest in a dedicated team of certified risk adjustment coders to ensure accuracy and compliance with the regulatory requirements, which can be expensive. An alternative would be partnering with a risk adjustment coding company with experience in providing HCC coding services.

If the patient information is incorrect or not documented properly it will lead to less reliable risk score calculations, risking inaccurate representation of their members health needs. Adapting to the ever-changing healthcare landscape and keeping up with HCC documentation requirements is extremely important to maintain data accuracy and remain in compliance.

HCC risk adjustment is based on physician-coded documents, claims coded by back-office personnel, and codes entered by HCC medical coders. A single mistake or misinformation can affect the rest of the chain at any point in the process.

Risk Adjustment Coding Challenges
3Gen Advantage

The 3Gen Advantage

Our team is experienced in helping organizations with risk adjustment reviews. We understand how fundamental the HCC framework is with risk adjustment coding, not only from a reimbursement standpoint, but also from a health management perspective. With the help of our workflows and strategies, we assist organizations improve their clinical documentation and coding accuracy and help them grow their business. Still not convinced? Here are some additional reasons to highlight the 3Gen risk adjustment coding services difference.

  • Boost efficiency
  • Increase revenue
  • Customer-driven approach
  • Maximize HCC coding accuracy
  • HIPAA compliant services
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