Value-Based Care Revenue and Outcomes: Impact of HCC Coding and RAF

Diagnosing for risk in VBC is the unsung hero fixing healthcare behind the scenes. In this blog, we dig into diagnosing for medical complexity & documenting with ICD-10 codes. 


Diagnosing for medical complexity

Physician diagnoses patients with all medical conditions.


One shift when transitioning to Value-Based Care is the need to diagnose very specifically for complexity, rather than simply diagnosing a disease. In the old Fee-For-Service (FFS) model, it would be reasonable to diagnose simply diabetes mellitus. In a VBC model, it would serve the patient better to diagnose with a high degree of specificity—type 2 diabetes mellitus with neuropathy—to fully capture the complexity and severity of the disease, ensuring that all conditions are documented and the plan of care is executed accordingly. 


“Medical complexity” is another way to say “How hard is it going to be to keep this patient out of the hospital?”


For patients with very mild chronic conditions, it is often easier to manage their symptoms, keep them on their meds, and keep them healthy; thus, not requiring intensive medical resources. Comparatively, patients with very complex diseases can be very resource-intensive, and require a great deal of time, attention, services, and oversight to manage their chronic conditions and maintain their health. Therefore, these patients with more complex disease states are reimbursed at a higher rate, to allow for more intense and expensive care.


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Documenting with ICD-10 Codes

Diagnoses are documented with the appropriate ICD-10 codes


ICD-10 codes are still the backbone of medical diagnoses, and typically the only codes used in a VBC arrangement. So the diagnosis coding that was learned in FFS arrangements is still at play, just with a slightly different focus – especially, when diagnosing chronic conditions.


Hierarchical Condition Categories are a subset of ICD-10 codes, therefore not all ICD-10 codes map to HCC codes. Each risk-adjusting diagnosis will alter the patient’s risk profile, with the more serious conditions increasing RAF score more than less serious. But some HCCs supersede others when they are within the same category. For example, E11.9 – diabetes without complication will add 0.11 to the patient’s risk score, but E11.22 – diabetes with chronic kidney disease will add 0.33. As the codes are hierarchical by category, the highest diabetes score will be the one passed along to the patient’s total RAF – not both. 


Risk follows the patient, not the provider

The risk score of a patient is tied to the patient themselves, not the provider. Diagnoses submitted to medicare by any clinician anywhere will add to the patient’s risk profile. Each patient has just one PCP assigned to them when they join a managed care plan, and that PCP will receive payment for that patient’s care, as they are the one taking on risk. 


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