Overcoming the costs of bad HCC coding education

HCC (Hierarchical condition category) coding is a complex and ever-changing field, and training clinicians in the traditional seminar format can cause significant pain points for healthcare providers and administrators. Here are just a few examples of the pain points that result from HCC coding education seminars:


Inaccurate or incomplete information: Traditional seminars often result in low retention, which leaves you with clinicians who may not provide accurate or complete documentation when coding for HCCs, which can lead to coding errors and non-compliance with CMS.


Difficulty applying the information: The seminars cannot provide hands-on training or clinical vignettes, which makes it difficult for attendees to apply the information they’ve learned in their own practice.


Lack of understanding of the most current guidelines: The seminars may not be up-to-date with the most recent guidelines and definition, which can lead to confusion and non-compliance.


Lack of ongoing education and support: The seminars cannot offer ongoing education or support, which makes it difficult for attendees to stay current with new information or retention.


Time and money wasted: Poor education seminars can be a waste of time and money – both for clinicians who attend them as well as the organizations that sponsor them.


Decrease in Reimbursements: Ineffective HCC coding education often leads to an increase in missed diagnoses and a decrease in revenue.


Audits and penalties: Bad HCC coding education often results in bad HCC coding, which can lead to an increased risk of audits and penalties from CMS.


Decrease in patient care: Bad HCC coding education can lead to an overall decrease in patient care, as providers may not be able to accurately diagnose and treat patients due to coding errors.


It is time for physician groups, hospitals and hospital systems to reevaluate the outdated methods of training clinicians on HCC coding and consider alternative options. While traditional HCC coding education seminars have been the norm for many years, they can be time-consuming, unengaging, and disruptive to the clinician’s daily workflow. Additionally, they simply are not as effective as other methods of training, which can lead to inaccuracies in coding and lost revenue for the practice.


Instead of relying solely on traditional HCC coding education seminars, physician groups should consider implementing a blended learning approach that combines different methods of training such as:


Online training modules: These can be accessed by clinicians at any time and can be tailored to their specific needs and experience level.


Self-paced learning: This allows clinicians to learn at their own pace and on their own schedule, reducing the disruption to their workflow.


One-to-one coaching: This can be done by pairing experienced coders with less experienced clinicians to provide real-world training and hands-on experience.


Using software such as the DoctusTech HCC coding education platform provides active education that helps clinicians engage with coding best practices, tests to run, things to look for, and ways to diagnose for risk in a Value-Based Care arrangement, helping to reduce the risk of audit penalties and fines.


Incorporating a blended learning approach can make training more efficient, effective, and engaging for clinicians, which can ultimately lead to improved coding accuracy, increased revenue for the practice, and reduced clinician burnout.


It’s also important to note that, even with the implementation of a blended learning approach, it’s important to have a mechanism in place to keep the clinicians accountable, so administrators know when and for whom a little extra one-to-one coaching and chart review could be beneficial.


Want to see the DoctusTech app in action? Schedule a demonstration today.

Risk, Revenue & Care: How HCC coding and RAF impact Value-Based Care Revenue and Patient Outcomes

The basics of RAF and how it is calculated.

Total HCCs for a single patient equal RAF score


Every VBC patient has a Risk Adjustment Factor (RAF) score, and the score follows the patient. The more medically complex diagnoses render a higher RAF score. The higher the score, the more resources required to care for that patient; therefore, Medicare pays more to care for that patient. No matter where the diagnoses and HCC codes originate, RAF scores follow the patient back to the group that has taken on risk for that patient. So if your patient sees a cardiologist and is diagnosed with afib, that will impact your capitated reimbursement from CMS. And that will also impact the care required to keep that patient healthy and out of avoidable hospitalizations.


Although there are 80+ HCC codes, Medicare has created 8 special groups of HCCs with similar diagnoses of differing severity: cancer, diabetes, COPD, renal disease, substance use disorder, cardiorespiratory failure, psychiatric disorders and pressure ulcers. HCC codes that belong to one of these groups may be overridden by a different HCC in the same group higher up the hierarchy.


For example HCCs 8-12 all involve cancer, from solid breast tumors to leukemia. If a patient has a cancer in HCC 8 and a cancer from HCC 11, the more serious category (HCC 8) will be the only one that is reimbursed. Also worth noting, lower numbered HCCs trump higher numbers in their group, and have a greater impact on RAF scores.


Medical complexity diagnosed & documented determines Reimbursement

CMS uses RAF scores to render capitated payments


As illustrated above, HCCs contribute to RAF through a somewhat complex relationship, but the key is accurate documentation of all patient conditions and treating the patient for the complexity that has been diagnosed. Each patient has a RAF score that typically falls within the range of 0.6 to 1.2. When looking at a risk contract, CMS reimburses for each patient according to their RAF score, adjusted for age, sex and regionally based on costs of care.


So the overall average RAF within a contract determines the overall reimbursement for that population. The payments are termed capitated (from the Latin word for head) as it is paid “per head” rather than per-action, or CPT codes submitted in a FFS arrangement. Often, revenue is looked at in a per-member per-month average (PMPM), where the total population RAF and the total PMPM capitated payments are reviewed to determine how well a contract aligns with regional averages, numbers per clinic, or per doctor’s panel.

What to expect during a CMS audit?

A CMS Medicare Advantage audit is a process used by the Centers for Medicare and Medicaid Services (CMS) to ensure that Medicare Advantage (MA) plans, also known as Medicare Part C, are complying with regulations and standards set by the CMS. The process includes several stages, including notification of the audit, preparation, on-site review, audit findings, and potential repayment or appeals.


Here’s a general overview of what to expect during a CMS audit:

  1. Notification of Audit: The provider will be notified by the CMS of the audit, and will be given a specific timeframe in which to prepare for the audit.
  2. Preparation: The provider should review their billing and medical records to ensure they are accurate and in compliance with government regulations. They should also review the CMS audit protocol and gather any supporting documentation that may be needed during the audit.
  3. On-site Audit: A CMS representative will conduct an on-site audit of the provider’s billing and medical records. The audit may last several days, and the provider should be prepared to answer any questions and provide any necessary documentation.
  4. Audit Findings: After the audit, the CMS representative will provide a report of their findings. If any errors or discrepancies are found, the provider will be given an opportunity to correct them.
  5. Payment Recoupment: If the audit finds that the provider has overbilled the government, they may be required to repay the overbilled amount.
  6. Appeals: If the provider disagrees with the audit findings, they have the right to appeal the decision.


It is important to note that the CMS audit process can be stressful and time-consuming, but by following the guidelines and providing accurate and complete information, providers can minimize their risk of overpayment recoupment and negative findings.


It’s always a good idea to be proactive and conduct regular internal reviews and compliance audits to identify and correct any errors or non-compliance issues before an official CMS audit takes place.


In summary, a CMS audit is a process used by the government to ensure that healthcare providers and suppliers are complying with Medicare and Medicaid regulations. During an audit, a CMS representative will review a provider’s billing and medical records to ensure they are accurate and in compliance with government regulations. Providers should be prepared to answer any questions and provide any necessary documentation.