Audits are no longer just for large payors, provider groups are feeling the pressure of rising compliance audits, and the playing field is complicated to negotiate. Some of this may seem unfair, but with the cost of medical fraud on the rise, the DOJ, CMS, OIG, HMS and all the other initials are not going to let up any time soon, if ever.
The DOJ sued Cigna in October, the Supreme Court refused to intervene on behalf of Molina Healthcare’s whistle-blower case, and more negative audit and antitrust cases are appearing daily.. You may be doing your best but that is no defence in an audit. The only things that matter are facts, documentation, accuracy, and pure compliance. Practicing medicine is an art, but documenting is a strict science, and anything less than precise documentation may result in poor audit outcomes and your company’s name up next in the headlines.
The DOJ is relentless, but not unpredictable. It turns out, they consistently target the same set of codes in nearly every suit. Apparently, the “low-hanging fruit” can be bucketed into four simple categories: Acute coded as chronic; Lack of clinical accuracy or supporting documentation (MEAT Criteria); and Diagnosing without changing the plan of care.
We’ve pulled together a list of “The Usual Suspects” – HCC codes that appear most frequently in DOJ audits, and married the specific codes with strategies to both find them in your EMR and avoid them in your coding. Access the most common offenders in our free report.
Back in 2004, CMS introduced HCC coding as a tool to help estimate Medicare costs. Today, HCC coding us used across Medicare Advantage plans, the Medicare Shared Savings Program, Medicaid, and private health plans – all deploying a variation of the risk adjustment model in order to quantify the upcoming cost of care for their member population, and as a mechanism of submitting that care need to CMS for payment. And yet, the question comes up more often than you may think: “What is HCC Coding?”
Even in the value-based care space, there is confusion around HCC coding, which ICD10 codes risk adjust, and how to diagnose and document accurately and specifically. So if you’re moving from fee-for-service into VBC, taking on risk for the first time, or a veteran at HCC coding for VBC, this article will clarify much of the confusion and simplify what HCC coding is, why it matters, how it is used and what the future holds for HCC and VBC.
Do Doctors Know HCC Coding?
First, clinicians typically have a good working knowledge of ICD-10 codes. And every org has their lookup functions baked into the EMR. However, not only do most ICD-10 codes not work as HCC codes, many of the traditional ways of diagnosing in the fee-for-service world are turned on their heads in VBC. So knowing or having access to ICD-10 codes is not actually that much of an advantage when learning HCC coding. In fact, in some cases, that knowledge can be a liability.
Knowing the code to document diabetes is great, but using that same basic E11.9 that you’re used to is not helpful when diagnosing in a risk model. You need to dig into the complications, the severity of the disease state, and both diagnose and document with high specificity in order to treat and afford to treat the full complications of the disease. If you under-diagnose, you will likely under-treat, and risk an avoidable hospitalization, the risks to the patient and the costs notwithstanding. So in the case of diabetes, a quick check of the toes could yield a missed diagnosis that is critical to the patient’s care as well as accurate RAF and adequate capitation.
What are HCC Codes?
Hierarchical Condition Categories – as the name implies, the categories relate to a hierarchy of of conditions, and it all works together as an efficient sort function to calculate the risk that the patient’s will be expensive. Think about it like this: A patient with mild diabetes as unlikely to end up in the ER due to their disease, so basic diabetes does not risk adjust; whereas a patient with severe diabetes with complex circulatory symptoms that have already led to amputation of one toe is at extremely high risk of ending up in the ER, and they will require a lot of personal and intense care to keep them out of the hospital. And care costs money, so risk and care are nearly synonymous. A higher risk diagnosis gets an HCC code with a higher risk adjustment score, which adds a higher multiplier to the capitation of that patient – meaning the government pays more dollars a month to maintain that disease and help that patient stay out of the hospital.
How do clinicians use HCC coding?
The primary use of HCC codes is to document new chronic condition diagnoses, and recapture chronic conditions being treated, and communicate those diagnoses to Payors and CMS in order to receive capitated payments.
How do HCC codes translate to revenue?
The payment model is obviously vastly different from the traditional fee-for-service (FFS) format where actions are performed, justified, transmitted as CPC codes and reimbursed by payors and/or CMS. In the VBC model, a patient is diagnosed with a specific chronic condition, that condition is documented and coded based on hierarchical condition categories that adjust the risk associated with keeping that patient healthy and out of the hospital. By taking on that risk, the plan or provider group is agreeing that, if given a reasonable amount of money, they will be able to maintain the health of that patient. That money directly ties back to the HCC codes documented, and is paid on a capitated model, with a certain dollar amount paid per-member per-month (PMPM). Those payments allow the overall organization to provide excellent care to the entire patient population, paying extra attention to those whose disease states have reached a complexity where significant resources are required to maintain optimal health. Whether for-profit or non-profit, the organization providing care will financially benefit from accurate diagnosis coding and aggressively proactive care.
How does HCC coding help doctors get paid?
When done correctly, practicing medicine in a Value-Based Care arrangement means more time for doctors, less administrative burden, less burnout and more time to spend per-patient. Smaller panels, and more help treating patients mean that a good doctor can provide truly life-changing care to patients without over-working or over-coding. And by practicing good medicine with proper HCC documentation, you will find your organization flourishing and your patient outcomes improving – all while actually decreasing the overall cost of healthcare. Sure, there is no such thing as a perfect system, but this is as close as we can get in today’s environment. And with an eye to continuous improvement, good coding and good care puts your organization squarely on the path.
How does HCC coding translate to patient care?
You cannot treat what you do not diagnose. And if you diagnose with an eye to changing the trajectory of the patient’s care plan, you are practicing good medicine. To diagnose without proper documentation denies the patient the care that comes from critical revenue. And to document without care is, simply put, fraud. So diagnose with high specificity and proper documentation to ensure that your clinic can afford to provide the kind and quantity of care that will keep your VBC patients out of the hospital. Better HCC coding = better care.
How long does it take to learn HCC coding?
Depending on the tools used for teaching and learning, it can be a years-long process fraught with frustration and difficulty – OR – it can be a simple weekly check-in on an app that uses modern learning methodologies to make mastery quick and easy.
How does HCC coding relate to compliance audits?
The number of compliance audits of provider groups has been steadily rising. The DOJ launches new lawsuits against both large payors and smaller provider groups with increasing penalties. And the Supreme Court has refused to step in and ease the pressure, letting whistle-blower cases proceed unchecked. Clinicians are doing their best, but that is no defense in an audit – the only thing that matters is facts, documentation, accuracy and pure compliance.
Practicing healthcare is an art, but documenting is a strict science, and anything less than accurate documentation vigorously maintained will likely result in negative audit outcomes and your group’s name landing in next month’s headlines.
CMS and DOJ have been increasingly scrutinizing payor strategies and billing patterns as it pertains to Hierarchical Condition Categories (HCCs). As more and more physician groups take on risk in the VBC models, it is imperative that physician groups do not make the same mistakes as their payor partners (intentionally or not).
Some of the most common offenses are fairly simple to avoid. But as we all know, simple does not mean easy. In fact, achieving simplicity can be far more difficult than creating complexity – which is what happens most of the time. A simple solution requires tremendous discipline.
HCC coding for acute conditions
As a rule of thumb, an acute code should not repeat 2 years in a row for a specific patient. And usually, even the first year is inaccurate. Acute heart attack is one of the most common errors penalized by CMS and the DOJ. One reason for this is misunderstanding how to document “history of heart attack” vs “heart attack.” Another version is chronic conditions that have been mis-coded as acute. There is a very short distance between upcoding and practicing good medicine.
It is sometimes appropriate to use these within the year where the acute event occurred, but the following year you must diagnose and document a different code. A third of the most common acute condition dinged by CMS is the combination of #1 & #2 – Acute Stroke and Acute Heart Attack.
Lack of clinical accuracy or supporting documentation – Medical diagnoses are complex and sometimes exist in the gray area between possibilities – but coding and compliance are hard rules. Picking the wrong code. Commonly misused diagnoses. While RADV audits are routinely looking for MEAT criteria, they’re not looking for clinical criteria or diagnostic accuracy.
Commonly misrepresented diagnoses: The exact criteria can be confusing even though the treatment can be the same for mild, moderate, and severe forms of certain diseases. Misrepresentation of the severity can result in overpayment from CMS, and legal and financial penalties – not to mention the obvious ethical concerns.
What is HCC Coding Without Plan of Care?
Now that a doctor has diagnosed a chronic condition, what is the plan to treat or manage the disease? A diagnosis that does not demonstrate a direct and deliberate impact on the plan of care is almost always incorrect at best, and in an audit, illegal. Diagnosing and documenting should function as a mechanism of providing care; documenting to document is never correct. So be on the lookout for conditions diagnosed and codes submitted that do not impact the plan of care. These are often targeted by CMS, both in OIG compliance audits and RADV audits.
How is HCC Coding improved by Education and 1-on-1 coaching?
Build a culture that connects patient care to diagnostic specificity and accuracy in coding and documentation. No doctor wants the business managers coming down from their offices, clipboard in hand, scolding about how code capture and RAF scores impact revenue. But every clinician understands the need to improve care and decrease cost. So start there – in VBC, practicing good medicine and providing better care starts at accurate diagnosis right through to rigorous documentation.
Documentation enables treatment, funds resources to provide care, ensures better health outcomes for patients and actually lessens clinician workload – when done correctly. Chart audits do not have to be brutal, they can be helpful, asking clinicians how a particular diagnosis changes the care trajectory, and helping document for maximum patient benefit. Internal meetings should focus on coding as care. And manual chart reviews should be performed by medical doctors to give timely 1-to-1 feedback. If this is done, the last error on the OIG’s list of usual suspects will go down:
How does HCC coding impact clinician workload?
It can go either way – with increased coding requirements becoming a burden, both to learn in boring seminars and to chase down in chart reviews. But with modern advanced app-based learning tools like DoctusTech, clinicians can master HCC coding in as little time as 5 minutes per week.
What is HCC coding to the OIG?
The Office of Inspector General of the Department of Health and Human Services is at the forefront of auditing healthcare fraud, and recommending action from the DOJ.
From OIG: Since its 1976 establishment, the Office of Inspector General (OIG) has been at the forefront of the Nation’s efforts to fight waste, fraud and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Department of Health & Human Services (HHS) programs.
In today’s healthcare landscape, the OIG is finding value-based care to be a target-rich environment, with special focus placed on Medicare Advantage programs, as these allow a small action (documenting a chronic condition that does not actually exist) to multiply into a year of capitated payments to an organization. The simple act of up-coding a condition into something more complex than it should be or over-coding by documenting a chronic condition that does not exist results in thousands of dollars per year in fraudulent overpayments.
What is HCC coding to the DOJ?
While the Department of Justice is not directly concerned with healthcare, they are very concerned about medical fraud, which defrauds the government’s medicare programs, and in extension, the American people. Most often, the DOJ takes on whistleblower cases, where an individual from inside an organization shares insider information regarding acts of upcoding or overcoding that are both large and systemic. These whistleblowers stand to profit significant sums, at times earning up to 20% of the total settlement. And with the recent Sutter case settling at $90,000,000, the whistleblower could potentially take home $18 Million. The False Claims Act ensures that the federal government has a means of penalizing organizations and individuals who, through filing false claims, defraud the government. While this law has been in place since the 1800s, it is getting renewed attention as the DOJ discovers millions of dollars in false claims specifically in Medicare Advantage programs, as these allow an organization to bill CMS with very little scrutiny or oversight.
Top mis-used HCC codes
We address this in a report, feel free to request it HERE.
Also, codes most found in unlinked chart reviews, and subject to RADV audits are detailed in our white paper, found HERE.
What are the requirements for HCC coding documentation?
Generally referred to as the MEAT Criteria, here are the four things you must have to document an chronic condition with an HCC code:
M = Monitoring by ordering or referencing labs, imaging studies or other tests
E = Evaluation with a targeted part of the physical examination specific to a certain diagnosis
A = Assessment of the status, progression or severity of the diagnosis
T = Treatment with medication, surgery, lifestyle modification, or referral to a specialist.
What are the best HCC coding tools?
What apps are available for learning, search, lookup, documentation? This may be a bit of a self-promoting softball, but if you haven’t checked out the DoctusTech app by now, you really should. Make time with a member of our team to see if the DT app is right for your team. Demo DoctusTech today.
What is the best way to change physician behavior around HCC coding
Notes and insights from a study published by AJMC on how to change physician behavior. “The authors evaluated methods for implementing clinical research and guidelines, in order to change physician practice patterns, in surgical and general practice. They evaluated the effectiveness of different implementation methods.”
And as we have demonstrated through successful behavior change in physicians using our HCC coding education app, the most common solutions aren’t the most effective when it comes to ongoing positive change in physician behavior. Want to learn how to change physician behavior? Let’s dig a little deeper into a review of reviews, revealing some hard truths.
We’ve been saying for years, lectures do not work. Emails do not work. If you want to know how to change physician behavior on HCC coding, don’t take our word for it. The American Journal of Managed Care released a systematic review evaluating fourteen medical reviews in an effort to understand which interventions are most effective in changing physician behavior for the better and improving patient outcomes.
It is evident from their publication that the methods of intervention most commonly deployed in teaching doctors HCC coding are rarely able to create lasting change in physician behavior.
What is the best tool inside the EMR?
The DoctusTech Patient Data Analysis Platform (PDAP) is the premier tool for Value-Based Care, living inside the EMR and helping clinicians find and use the best HCC codes, track and manage care associated with chronic diagnoses, and learn which codes to use for which patients – all while reducing clinician workload. It helps readdress conditions diagnosed last year, significantly improving recapture rates. And it helps administrators see into the data by clinician, patient, clinic or by codes. Learn how the DoctusTech PDAP can help your patients and your doctors live happier, healthier lives. Demo DoctusTech today.
The Department of Justice has filed a new lawsuit against Cigna for overcharging the federal government by purposefully inflating how sick its Medicare Advantage members are.
Federal prosecutors previously declined to intervene in this whistleblower case, but have now seemed to change their minds about it.
The lawsuit brings up a very important point: Medicare fraud is a widespread practice. This lawsuit has just been another push by the government to crack down on insurers who exaggerate enrollees’ conditions in order to get more money from Medicare.
Over the past 2 years, the DOJ has joined separate, similar lawsuits against Medicare Advantage plans run by Kaiser Permanente and Elevance (formerly known as Anthem) and settled cases with several other similar organizations.
The lawsuit focuses on risk adjustment
The lawsuit focuses on risk adjustment – a process in Medicare that pays insurers more if patients are sicker than average. Some patients are assigned a higher ‘risk’ score’ than others due to conditions like diabetes, heart disease, etc.
Risk adjustment is a program to encourage insurers to cover people who might be considered a higher risk, even though they might be healthy. However, the current risk adjustment program also gives incentives to insurance companies and their vendors. They may prioritize coding diagnoses and bundling them together depending on your age or other factors.
The lawsuit specifically claims Cigna abused in-home assessments, where nurses and other clinicians go into a patient’s home and conduct health screenings.
The DOJ said Cigna’s home visits were designed to generate revenue for Cigna, not to provide medical care or treatment. They cited several instances in which people were diagnosed with things like rheumatoid arthritis but never received the blood tests they needed to confirm the diagnosis.
The practice of adding more conditions without verifying their accuracy is illegal. Every year, insurers have to attest to Medicare that they are following the rules and practices set by them. The overall practice is extremely profitable for Medicare Advantage insurers – potential profits could be thousands of dollars per year for just one patient.
The lawsuit by the DoJ is a cautionary tale on why it is imperative and critical for healthcare service providers to make their doctors compliant by coding accurately, documenting everything and providing proper justification.
How DoctusTech Helps Protect Against Actions Like This
HCC Coding Education in an app: DoctusTech helps train clinicians on proper VBC diagnosis requirements in a fun and engaging app. Through clinical vignettes and gamification, doctors learn quickly and accurately how to diagnose for risk, which HCC codes to use for what, and how to meet MEAT standards on all documentation. Learn how the DoctusTech app can help keep your team compliant today.
HCC Coding Implementation In Your EMR
DoctusTech Patient Data Analytics Platform: The PDAP sits inside your EMR and provides a simple pathway to capturing unique accurate diagnosis codes, recapturing appropriate past codes, and document appropriate MEAT standards were met to ensure highest data integrity and audit preparedness. To assist admins manage recapture codes across the organization, the integrated solution provides an Admin Portal that lists the recapture rates across clinic, provider, and patient level. This ensures that you have all the necessary information at your fingertips on clinics, providers, and patients as it relates to HCC coding, documentation, accuracy, and more.
According to the American Journal of Managed Care (AJMC), the least effective method for continuing medical education (CME) for clinicians is distributing printed materials: emails, PDFs, flyers, email blasts, and so on. Many medical professionals believe that clinician education should be concerned with encouraging continuous development rather than simply raising consciousness. What, then, are the most effective strategies for accomplishing the goal of both informing and changing clinician behavior?
The AJMC says that the methods of intervention most commonly deployed in teaching doctors HCC coding are those same methods determined to rarely create lasting change in physician behavior (classroom lectures, emails, PDFs, flyers, email blasts). So most frequently utilized modes of learning are clearly out.
“When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients.” – Dr. Villaplana-Canals, Florida, DoctusTech App User
Both the AJMC and common sense agree that active education methods and multifaceted interventions are the most effective when it comes to educating and changing physician behavior. The DoctusTech mobile app provides active education and multifaceted interventions through clinical vignettes. In other words, our app helps you achieve your desired outcomes – as a physician, or as an operator for your physicians. In fact, we provide the most effective intervention methods, demonstrated by consistently better outcomes.
Learning in the app is driven by clinical vignettes, placing clinicians in a real-life patient scenario, presented with symptoms and facts, and then asked questions about diagnosis and documentation, all in an effort to alter the method of diagnosing from the fee-for-service approach most physicians were educated in to a value-based care system, in which chronic conditions are diagnosed in a very specific manner, with an eye to risk and outcomes. By including any and all information about the diagnosis that impacts risk adjustment in the diagnosis, clinicians learn to both diagnose and document those diagnoses with supporting information in the chart.
“The mobile app is wonderful, in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking.” – Teresa, Director of Clinical Documentation Improvement
For clinicians, behavior change is accomplished through learning in clinical vignettes with the DoctusTech mobile app. Doctors learn more deeply and permanently about diagnostic procedures and proper documentation by sitting through a clinical vignette. The socratic method is a highly regarded teaching tool as well as being one of the most commonly used teaching strategies in medical school. The socratic approach is utilised by medical students as they learn by questioning in clinical vignettes. It is fitting, therefore, that they will gain a new store of knowledge through clinical vignettes.
“It does reinforce for us something that, although most doctors use a problem list, most of the problem lists … ended up being too long, too nonspecific, and very unwieldy to use in the clinic. The training taught me to make sure you have the linkages and causations clearly laid out.” – Dr Joseph Bateman, Medical Director, Christ Hospital, DoctusTech App User
Clinicians can justify the RAF score impact of those diagnoses by supporting them with appropriate documentation that meets the MEET criteria. When there is an audit (When, not If), their charts are proper and in order, and their patients are well cared for.
Rather than diagnosing “diabetes” a DoctusTech educated physician would instead test for complications and diagnose a specific disease condition, accurately reflecting the capitated payments for that person’s care. The behaviour change comes from switching from one ICD-10 code that doesn’t risk adjust to a more specific diagnosis, using a different ICD-10 code that does adjust the risk of that patient and accurately reflects the change in capitated payments for their care.
Book a demo today, and experience DoctusTech Mobile App’s transformative teaching techniques for yourself!
Value-Based Care is a natural movement toward the benefit of the patient with a reduction in costs by aligning all incentives in the right direction. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based Care has the potential to be a significant win-win for patients and providers. And in the end, isn’t that why you spent all those years pursuing your medical training? Value-Based Care is for patients, and for the providers who care for them.
The market is now moving towards building value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.
Why is HCC Coding Important for Value-Based Care?
HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. And Hierarchical Condition Category Coding is the language clinicians use to document the diagnoses of chronic conditions and the complications and various disease states that contribute to risk.
Why should doctors care about HCC coding?
Doctors should, first and foremost, care about patients – and they do. But as a mechanism of that care, doctors must diagnose with specificity and document with accuracy in order to provide care and the revenue that affords that care. And HCC coding is how that is done. HCC coding is the documentation foundation for most of the value-based care arrangements used today. With “value-based care” usually being equated with Medicare Advantage, in coming years we believe that VBC will be incorporated into nearly all types of financial models.
HCC coding falls under the broader term of Risk Adjustment (RA) models for prospective payment. These models are designed to determine risk scores and assign a fee according to the patient’s level of risk.
In the Medicare Advantage world, these models use certain demographic and HCC codes to assign a risk score to patients known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.
This prospective payment model based on RAF does 2 things:
Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.
Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.
How can DoctusTech Help?
We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.
DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement.
You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization.
In December of 2021, the Mayo Clinic published an alarming report: ⅓ of physicians surveyed intended to reduce their work hours – that represents 336,000 doctors. While—and I hope you are sitting down—1 in 5 physicians intended to leave their practice altogether – 20%, or 204,000.
Burnout from workload, COVID-19–related anxiety/depression, and fear of contracting the disease. Now, some of those burdens have certainly eased over the past 10 months – but the prevailing concern of burnout from overwork has hardly abated.
Burnout is a widespread problem in any industry, but the stakes are even higher in healthcare with lives of patients on the line. Quality and safety of care is our top priority and errors or lack of awareness can lead to terrible consequences.
With burnout on the rise and VBC/HCC knowledge requirements continuing to grow, it can feel like there is an impossible riptide in front of today’s clinicians. And with healthcare relentlessly marching in the direction of Value-Based Care, it’s no wonder why new clinicians have a difficult time onboarding. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.
The DoctusTech HCC Coding App is designed with a sole purpose in mind: to reduce clinician workload, and make it easier for them to diagnose, and ultimately, take care of their patients.
The Socratic method, clinical vignettes, and question and answer sessions are the most effective methods for capturing long-term knowledge. This is how doctors were taught in the first place, and this is the best way to do it. With DoctusTech, they can learn HCC coding in the same manner—from other doctors using clinical vignettes—on their own time, requiring only an average of five minutes per week.
The DoctusTech Mobile App is based on our successful HCC education and retention strategy, which relies on clinical vignettes customized to the clinicians’ weaknesses and strengths, which are sent to their mobile phones every week. With an engagement rate of 90%, DoctusTech App results far exceed any other learning tool, technology, or strategy.
After using the app for HCC coding education, clinician RAF accuracy is consistently increased based on the learning data.
What methods does the app use to accomplish this?
Our app gamifies the learning experience, connects clinicians with one another, allows them to compete for real prizes, and provides administrative support. In addition, the most advanced HCC code search tool in the world is available. Clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!
If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most.
HCC coding improves the quality of patient care and reduces the cost of healthcare. But, like any tool, it’s only effective if the people who use it have it mastered. That’s why it’s so important to provide HCC coding education across your organization. In this article, we will share how DoctusTech helps deploy HCC coding education across your organization.
At DoctusTech, we are always eager to assist healthcare organizations boost HCC training programs. We believe that solving the three shortcomings of risk adjustment—the data gap, the workflow gap, and the knowledge gap—is critical. Most available solutions address only the data or workflow gaps. However, if your clinicians don’t have the right knowledge, you won’t obtain the outcomes you desire no matter what you do to resolve the data and workflow issues. We strongly believe that if you resolve HCC coding knowledge challenges, your data and workflow issues will be resolved along the way.
The DoctusTech Mobile App is designed on our successful HCC education and retention strategy that relies on clinical vignettes customized to the clinicians’ strengths and weaknesses, which are sent to their mobile phones every week. With a 90% engagement rate, DoctusTech App results far surpass any other learning tool, technology or strategy.
According to the learning data, we consistently achieve a significant increase in clinician RAF accuracy after they start using the app for HCC coding education.
How does the app achieve this?
Clinicians can use our app to gamify their learning experience, engage with their peers, compete for real prizes, and receive administrative support. Our app also comes with the most sophisticated HCC code search tool available on the planet. In addition, clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!
Clinical Vignettes – The secret sauce!
Most doctors who have just graduated from medical school or residency programs know little to nothing about coding for risk adjustment and value-based care. In the past, these clinicians were forced to sit in seminars and learn the correct codes so they could diagnose and document them properly. Every other important medical fact is learned in clinical vignettes, so clinicians have difficulty retaining and applying information learned in boring seminars or email blasts. Simply put, incorporating new HCC codes into daily practice is hard – which is why the DoctusTech HCC coding education app is so vital.
Doctors prefer to learn using the Socratic method, clinical vignettes, and question and answer sessions, because it is the most effective way to capture long-term knowledge gain. This is how they were educated, and this is the best way. DoctusTech enables them to learn HCC coding in the same manner—from other doctors, using clinical vignettes, on their own time, requiring only an average of five minutes per week.
Get in touch to learn more about how DoctusTech helps!
“I don’t care if the RAF goes up or down, I only care if it’s accurate.”
Dr. Farshid Kazi, Co-Founder, DoctusTech
If an organization is caught over-coding, up-coing, diagnosing conditions that either do not exist or are not supported in the chart, the cost of these errors can be very high. Audits are no longer just for health plans, provider groups like Sutter, Kaiser (and many others) have also been audited by the DOJ and hit with heavy fines.
On the other side of the board are many plans and provider groups that are struggling to diagnose and accurately document chronic conditions that truly do exist and risk adjust, leading to poor performance in VBC contracts and clinician burn-out.
RAF accuracy is achieved through a perfect balance of accurate diagnosis and accurate documentation.
What is Risk Adjustment Factor Scoring
Risk adjustment factors are used to estimate the expected outcome for a patient based on a number of different factors. One important factor is the patient’s age; other factors include socioeconomic status and comorbidities such as chronic illnesses or conditions. Each of these can be scored to give a single risk adjustment factor score.
DoctusTech Enables 30% Rise in RAF Accuracy
We teach clinicians how to think about chronic conditions, improve diagnosis at the point of care, and help documentation and HCC coding – all in a lovable mobile app. And not only do clinicians learn how and what to code, the app is also the most powerful HCC code finder in the palm of your hand. Look up the code through a variety of intuitive queries, by tests that might indicate a diagnosis, and by related conditions – complete with complexities and branch-points to help drill down into greater specificity.
While we cannot share sensitive client data, we can confidently state that a 30% increase in RAF accuracy is well within the normal range for our clients.
DoctusTech Helps by Boosting Clinician Knowledge and Changing Behavior Just by Engaging With a Lovable Mobile App
The app uses the classic learning technique we all grew to know and love in med school: the Socratic method. By posing questions within a clinical vignette, clinicians learn—and remember—how to diagnose, code and document for risk adjustment. By increasing the fund of knowledge around diagnosing chronic conditions, the app improves unique code capture and documentation, boosting RAF accuracy over a very short period of time. After the initial self-assessment, clinicians are only asked to spend about five minutes per week engaged on the app, and behavior change outpaces traditional HCC teaching techniques by a significant margin.
DoctusTech HCC Integrated Platform
Instead of clinicians having to go to various external data sources to gather information, DoctusTech’s HCC integrated platform, HCC 360, consolidates all data sources and presents them to clinicians while they are writing progress notes. Here’s how you can achieve greater RAF accuracy with DoctusTech:
Improve Patient Visits: Based on your patient’s chart, get real-time prompts for questions to ask or labs to consider.
Automate Chart Review: Translate your patient’s chart into HCC code using our A.I. in seconds, based on evidence-based medicine.
Faster Progress Notes: You won’t have to wade through third party portals or paper suspect codes anymore; we bring all sources into your EMR to simplify your life.
As healthcare continues to evolve, it is crucial that providers get educated and improve their skills in using HCC codes. DoctusTech is a revolutionary new way to improve the accuracy of HCC coding by making sure you know exactly how to code each condition. Our simple mobile app that engages clinicians in an easy guided learning experience while they file HCC coding notes. After only five minutes of training, clinicians can quickly and accurately code their own charts and boost the accuracy of their efforts.
Amazon has announced plans to buy OneMedical for $3B. OneMedical is a brick and mortar plus digital healthcare marketplace that operates in several major U.S. markets. The acquisition is Amazon’s latest move in the healthcare sector, and analysts say it could be a sign of bigger things to come. This is not Amazon’s first foray into the healthcare market, but after the Haven experiment closed down, the company has kept a relatively low profile while it tests new business models. In June, Amazon was among several investors that participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm that offers an edge security service for cloud networks and internet-facing applications and services. A few months earlier in March, news broke that Amazon had hired former pharmaceutical executive Bernard Jegou as its new vice president of e-commerce strategy and new business development.
And in a very public failure back in 2017, Amazon partnered with Berkshire Hathaway and JPMorgan Chase to form an independent healthcare company called Haven, which it quietly scuttled mid-pandemic, February, 2021. Read on to learn more about how this acquisition could indicate continued interest from Amazon in the healthcare space — or if it is just another pivot from one of its many subsidiaries.
What is OneMedical?
OneMedical is a primary care practice and digital healthcare marketplace that uses technology to reduce healthcare costs and increase convenience for patients. The company has built a network of more than 500,000 doctors and has partnered with health insurance providers across the country to serve more than 3 million members. OneMedical offers a range of services, including access to an online portal for patients and a concierge service for their members. OneMedical’s network of doctors comes from a variety of specialties, including general practice, pediatrics, OB/GYN, and family medicine. OneMedical also offers telemedicine services, including video visits with doctor consultations and prescription refills.
Why might Amazon be buying OneMedical?
While Amazon has not released any details about why it is acquiring OneMedical, analysts say this acquisition may be a sign that the company has larger ambitions in the healthcare sector. Amazon has a track record of acquiring companies in sectors where it sees potential for disruption and then gradually building out its business there. This could be a way for Amazon to expand its e-commerce business into health insurance. It could also be a sign that Amazon wants to become a one-stop shop for healthcare services. Amazon has been experimenting with new business models in the healthcare space for several years now. The partnership with Berkshire Hathaway and JPMorgan Chase formed an independent health company called Haven began with promise, but was quietly closed a few short years later. And in June, news broke that Amazon had participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm whose edge security service could help internet-facing applications and services like those that run on Amazon’s AWS platform.
Possible reasons for the acquisition
Analysts say there are a few reasons why Amazon might be interested in acquiring OneMedical. Amazon may be looking to expand its reach into healthcare marketplaces beyond its partnership with Berkshire Hathaway and JPMorgan Chase to form an independent health company called Haven. Acquiring OneMedical could give Amazon a foothold in the digital healthcare space, which has been growing rapidly. Amazon could also be interested in OneMedical’s digital platform for its members. Having an online presence and digital tools for patients and doctors could let Amazon expand into other healthcare sectors, including pharmacy. And Amazon might be interested in the data that OneMedical has on its members, which could be useful for the company’s future endeavors in the healthcare space.
Amazon has bigger plans in healthcare
Analysts say the acquisition of OneMedical could signal Amazon’s intent to become a major player in the healthcare space. It is unclear exactly what the company’s strategy will be, but it is likely that Amazon will focus on improving the customer experience across the healthcare sector. Amazon is no stranger to industries with high-barrier-to-entry business models. The company has made inroads in industries such as grocery and e-commerce, as well as more traditional businesses such as manufacturing and cloud computing. Amazon has long been a disruptive force in the retail sector. The company has reshaped consumer expectations of online shopping and shifted the entire retail landscape in its wake. The company’s foray into digital and bricks-and-mortar retail has been a boon for customers, and it has also provided a boost for shareholders: Amazon’s stock is up almost 102% over the past year.
Value-Based Care and Risk Adjustment
Experts say that Amazon’s involvement may help OneMedical’s risk management as the adoption of more value-based care programmes continues. Most of One Medical’s business has traditionally been generated from charging commercially insured patients per-visit fees, but since the acquisition of Iora last year, Medicare patients are now served, and revenue is captured as a result of savings through risk contracts. According to their website, OneMedical serves scores of Medicare Advantage plans, though patient numbers were not readily available. Scaling value-based care is challenging for providers without extensive data experience. Those in primary care, retail health, and telehealth should be concerned, experts say.
The big question: Is this a pivot or a sign of future intent?
Analysts say Amazon’s acquisition of OneMedical may be a sign that the company is pivoting from its health technology investments, like Zscaler, and looking to establish a more direct presence in the healthcare sector. But it is also possible that Amazon has more ambitious plans in the healthcare space that the acquisition of OneMedical is only the first step in. Whatever Amazon’s end goal is in the healthcare sector, it seems likely that the company will take a slow and methodical approach to growing its business. After all, Amazon has plenty of experience building new businesses from the ground up, and it has a track record of entering new sectors and disrupting existing players with a more customer-friendly approach.
DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement. You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization.
And without a tool to get clinicians quickly up to speed on diagnosing for risk at the point of care, coding accurately and documenting correctly, you will be stuck. Stuck in boring seminars that rarely affect lasting behavior change; stuck with missed diagnoses and missed revenue targets; stuck with patients missing out on essential care; stuck with overworked clinicians; stuck.
How do clinicians learn HCC coding?
This is where DoctusTech Helps. We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.
And clinicians earn 25 hours of CME per year, while they learn HCC coding in a non-boring app!
In SCUBA diving, the diver must add just the right amount of weight to maintain perfect positive buoyancy; too much and you will sink, too little and you will bob on the surface like a cork. Risk adjustment in value-based care has some similarities: a successful VBC program will diagnose and treat just the right conditions. Not over-coding, and not under-diagnosing.
Clinicians learn HCC coding better in clinical vignettes
And doctors coming out of medical school and even residency programs know little to nothing about HCC coding and diagnosing for Risk Adjustment and Value-Based Care. Traditionally, these clinicians sit in seminars getting force-fed codes in an effort to teach them how to accurately diagnose and document with the appropriate HCC codes. Unfortunately, this is not how every other vital piece of medical information was learned, so clinicians struggle to retain the information and utilize it in daily practice.
Medical education is all about the Socratic method, question and answer, clinical vignettes. Doctors learned to learn this way, and they prefer it. Which is why DoctusTech helps doctors learn HCC coding the way they like to learn – from other doctors, in clinical vignettes, on their own time, and in an average of 5 minutes per week.
Truly, DoctusTech helps clinicians learn HCC coding. And when clinicians master diagnosing for risk with HCC codes, your whole VBC program improves.
See more ways that DoctusTech Helps:
DoctusTech Helps: Increase RAF Accuracy
DoctusTech Helps: Decrease clinician workload
DoctusTech Helps: Deploy HCC coding education across your org
Why is HCC coding training important? Without proper coding, it is impossible to diagnose accurately, treat effectively, document those diagnoses, or achieve revenue goals. Coding training will help you master the skills you need to properly code patient records, so investing in HCC coding training might be the right move for you! Read on to learn more about HCC coding training!
What is HCC coding?
Hierarchical condition category (HCC) coding was created to estimate future health care costs for patients. The Centers for Medicare & Medicaid Services (CMS) HCC model was established in 2004 and is increasingly being used as value-based care gains traction. The HCC model relies on ICD-10-CM coding to assign patients risk scores based on their medical condition. Each condition is associated with an ICD-10-CM code. For example, a patient with few serious health problems is likely to have average health care costs for a specific period of time. Patients with many chronic conditions, however, are more likely to have higher health care utilization and costs.
Why is HCC coding training so important?
As we mentioned above, proper healthcare coding is important for a number of reasons. However, even the best healthcare providers cannot properly code without the right training. If you are new to the healthcare industry, you will need training to learn the coding system and understand the complexities of accurate diagnosis and documentation. If you have been in the industry for a few years but have not kept up with the latest coding trends, you may also need training to refresh your skills. Whatever your situation, it is important to take the time to invest in HCC coding training. This training will help you master the terminology and coding systems that are used in the healthcare industry. It will also help you learn how to properly diagnose and document for better patient care.
Which platforms and tools are effective?
HCC coding training can be delivered in a variety of ways. Depending on which courses you decide to take, you may be able to access them online or on your mobile device. Most HCC coding training courses will include videos, interactive activities, and practice tests. These tools can make learning easier and more effective. They can also help you retain the information you learn effectively. If you are looking for HCC coding training, it is important to find a platform or a course that fits your learning style and skill level. If you are new to the industry, you may want to take a beginner’s course. If you have been in the industry for a few years and just want to refresh your skills, you might want to take an intermediate or advanced course.
3 Things to include in your training plan
When you are ready to start your HCC coding training, it is important to make sure you have a plan in place. This will help you stay motivated and on track and make sure you finish before the course’s deadline. There are a few things you should definitely include in your plan.
Set specific goals
Before you begin coding training, you should sit down and set some specific goals for your course. What do you hope to achieve by the end of your training? By setting specific goals, you will know what you are working towards and have something to motivate you.
Set a schedule
It is important to set a schedule and stick to it. This will help you stay motivated and make sure you do not get overwhelmed by the coursework. Make sure you allot enough time for studying each week and do not try to cram. A healthy pace is achievable at 5 minutes per week, if you have the right tools.
Finally, during your coding training, it is important to keep your eye on the prize. While coding is interesting and can be complex, you do not want to get so involved that you lose sight of your goal. Stick to your schedule, do not try to push yourself too hard and you will be on track to finish in time.
Get Started Today
Doctus Tech is the best way for clinicians like yourself to start learning to diagnose with HCC codes. Benchmark yourself with other clinicians, identify your team’s knowledge gaps and benefit from a 30% increase in RAF accuracy. Sign up for a 14-day trial now!
Risk adjustment coding is a vital part of any managed care organization. It helps to ensure that patients are appropriately diagnosed and documented accurately according to risk level, which in turn allows the organization to receive appropriate capitated payments to provide all the care needed to reduce avoidable hospitalizations and achieve maximum health. And regardless of how challenging and time-consuming it can be to implement, getting it right is vital on many levels. Diagnosing and coding for risk can be tricky.
It is not always obvious how complex and risky a condition is, especially because some patients are at higher risk than others for diseases like depression or schizophrenia, but many conditions can be difficult to diagnose. Those who appear low-risk might actually be high-risk, once you dig deeper into the specific diagnosis details. There are thousands of potential codes and conditions to diagnose that can be used to determine risks. There is no perfect formula for every managed care organization; you have to find protocols for training and improvement that work best for your clinicians and operators. Let’s take a look at some of the challenges involved in risk adjustment coding and how to get it right.
Determining risk is difficult
When implementing a risk adjustment program, make sure you have a team on hand with strong coding and data management skills. These team members should be able to look at each patient record and determine both the conditions that have been diagnosed as well as the documentation criteria to be applied to that patient in the chart. This team will be responsible for determining and documenting diagnoses that correlate to the risk level of each patient. This task can be difficult since mastering HCC coding for risk adjustment requires a lot of learning and is often different than standard ICD-10 coding. But there are modern tools for mastering this, so do not lose hope.
Risk adjustment requires a lot of data
Risk adjustment also requires a lot of data. The more information you have about each patient, the better you are able to diagnose based on their true conditions and related risk. If you do not have enough data about a patient, or lack consistent data throughout the lifetime of a patient relationship, you will have a hard time determining their true risk level.
For example: Patient A has been a patient for 10 years, and Patient B has been a patient for 2 years. If you’re trying to diagnose the patients, you’ll have to take into account their lifelong risk factors and current health status. This includes things like socioeconomic status, age, family history of certain diseases, how much they smoke, and more. If you have a few years of data points on Patient A, and only a few months of data points on Patient B, you’ll be able to diagnose Patient A more accurately.
Coding errors are common
Coding errors are common in risk adjustment, but they can be avoided with consistent training, accountability, strict internal audit procedures, and improved clinician buy-in. Coding errors can lead to overcharging or undercharging the CMS, resulting in either missed earnings or painful charge-backs. Coding errors can be caused by a number of different factors. For example, mistakes could be made when determining which diagnoses apply to patients, which codes to use for the diagnoses, or what to document to justify the diagnosis in the chart. Diagnoses require clear communication as well as consistent documentation on all patient records.
It is only going to get harder.
The bad news is that risk adjustment is only going to get harder. New technologies like AI, voice recognition, and machine learning are changing the way health care providers analyze and manage data. While these technologies will make many aspects of coding and managing data easier, they will also make it more complex by introducing even more variables and data points to consider. So while risk adjustment could be more challenging, there are tools available that simplify the process both in training and inside the EMR.
Risk adjustment is vital, because it ultimately determines what type of care an individual patient needs and how much risk the organization is taking on, managing that care. It is important to ensure that your organization is accurately diagnosing and documenting so that patients stay healthy and your organization has the needed revenue to manage their care.
HCC coding education is a fast growing need for physicians. To meet the demands of today’s fast-paced and dynamic healthcare environment, many are now accelerating their transformation from a hospital-centered fee-for-service model to a more patient-centered model, and Value-Based Care is at the forefront of this change. The increased HCC coding knowledge requires clinicians to become more efficient with their time and resources as they are forced to master HCC coding in the gaps between patient care.
The focus on implementing coding education programs for clinicians is a hot topic. Unfortunately, many of the strategies being deployed actually add to the challenges clinicians face in the day-to-day. They do this by attempting to educate with outdated methods, forgetting some of the tried-and-true teaching techniques that worked so well in med school. Namely, clinical vignettes deployed using the Socratic method. In order to achieve the proficiency they need to code efficiently in real time, today’s clinicians need a solution that works well, without adding to their already stretched workload.
Whether you are just getting started with your organization’s coding education strategy or you want to take it to the next level, this blog post compares the four key HCC coding education strategies, highlighting their strengths and weaknesses.
1. Lecture by Zoom / Classroom
The classic classroom setting, training through seminars deployed in person or over Zoom. This method does allow you to reach a massive audience and deliver identical content to them.
If only doctors learned this way, it just might work! Unfortunately, most doctors come out of med school hard-wired to learn through clinical vignettes and the question and answer techniques, AKA the Socratic method. Why? Because while some people do not learn well in a lecture setting, med school teaches doctors how to retain massive amounts of information using this proven teaching strategy.
2. One-to-One Coaching
One-to-one coaching is the gold standard of HCC coding education. If there was one coach for every 5 clinicians, and if every clinician had time to be coached, this could work. And if every clinician learned the same way, it would work. But that is not the case! This strategy has its advantages. The sessions are intense and generally effective, as it results in an immediate correction to a clinician’s thought process. But this strategy will only work if clinicians have unlimited time and nearly unlimited coaches, which they do not. This method is super time-consuming, and do not forget, to organize this, you would need a massive staff to run the entire thing. Also, unlike Zoom classrooms, your reach is limited by geography.
3. Email Blast
Other than the fact that it does not work, it is great! Email is fast and easy, but also super easy to ignore. Whether you opt to share all the codes in a single email, or drip out Code of the Month in a series of emails, it still falls flat. Easiest to deploy, easiest to ignore, and hardest to retain.
4. DoctusTech App
We admit to a certain bias, but hear us out. Learning can be done on the doctor’s timeline, and there is no scheduling required. Track the progress and performance, and help them to learn more and focus on areas needing attention. The DoctusTech app is ideal for larger groups, helping clinicians learn without negatively impacting workload or patient care. JIT Learning enables clinicians to learn what they need when they need it. And without the limits of geography, the same HCC coding education can be deployed to all clinicians at once. No coaching staff to hire, train, deploy and manage. Accountability across the organization. Ease of use for clinicians with only a five minute lift per week.
To make learning interesting, the app uses gamification to keep things competitive and fun. Clinicians can see how their peers are doing, and that competitive drive kicks in, pushing learners to engage even more. And when new information, rules, and codes come out, the app serves content to rapidly update the whole org. This app is cost-effective, saves time, and provides real-time behavior change.
HCC Coding Education Matters
No matter where you are in your value based care journey, HCC coding education is a vital tool that your clinicians need right now.
The best way to learn HCC coding is in the DoctusTech app. The second best way is deploying an army of coaches. And if you are still using email or seminars to onboard new clinicians and teach HCC coding to your doctors, please schedule some time with our team. The DoctusTech app is less expensive, more effective and far simpler to deploy, use, manage and maintain than any of the other HCC coding education strategies.
Learn More about HCC Coding Education
Book a demo to see the best HCC coding education strategy in action.
As the U.S healthcare system transitions towards value-based payment models, independent clinicians and physician groups continue to face HCC coding challenges that not only impact their bottom-line, but patient care as well. On top of all this, the pandemic has added a significant burden to the already stretched clinician workload.
Here are 4 key HCC coding challenges clinicians are facing now, and how they can overcome them.
Physician training for HCC coding – Physicians are already working tirelessly to provide excellent care to their patients. Asking them to learn HCC coding through brute-force via zoom calls, classroom seminars and email blasts is a bridge too far. On the other hand, the focus on value-based care has made it imperative for physicians to know and understand HCC coding so that they can accurately document patient records. So clinicians know they need to know, they just don’t have an effective and engaging mechanism for efficient and effective learning.
Revenue impact due to incorrect coding – Accurate HCC coding is necessary for accurate reimbursements and patient care, and inaccurate coding can directly impact the bottom line. That is why it is imperative that clinicians and staff be well trained in HCC coding. And the complexities don’t stop there. HCC codes not only impact RAF scores, they also interact directly with patient care, and a fair level of decision support is required , as HCC codes are not intuitive.
Poor HCC integration with EMR systems – When HCC coding does not integrate with the EMR, it creates a complex struggle for clinicians and physician groups. This not only leads to unintentional errors, but makes workflows more difficult and adds to the burden of an already heavy workload. It is critical to put a system in place that teaches clinicians to accurately document HCC codes on every patient, and integrates within the EMR.
Lack of trained HCC coding professionals – Staffing shortfalls not only plague small practices, but larger physician groups are short-staffed as well. A lack of well-trained staff may be related to revenue or rising salaries, which sometimes small practices are unable to sustain. And when larger hospitals acquire smaller practices, a shortage of trained staff is often just one side-effect. Training clinicians and non-clinical staff on HCC coding is vital.
Transitioning to a value-based care model will never be seamless until these challenges are solved. How? With our unique suite of HCC education and EMR integration tools, enabling physicians to learn HCC coding and integrate an AI-powered HCC coding system into their existing EMR platforms to drive efficiency and accuracy.
To learn how our HCC coding app lets physicians train for HCC coding click here.
To understand how our EMR integrated platform works, click here.
RaDonda Vaught was just sentenced to three years of supervised probation. The former Vanderbilt University Medical Center nurse was found guilty of negligent homicide and gross neglect of an impaired adult in the death of a patient, because she administered vecuronium rather than Versed.
A tired, overworked nurse could not find the prescribed medication in an automatic drug dispensing cabinet, so she used an override and grabbed the wrong drug. Her patient died, and she was convicted of two felonies.
Burnout is a pervasive evil in any industry. But in healthcare, the stakes are measured in lives, and a career-ending error could also land a well-meaning provider in court, battling more than a malpractice suit.
The Rise and Fall and Rise of Physician Burnout
A study from 2019 demonstrated a decline in physician burnout [Source]. Good timing, as the burnout decline preceded an overall healthcare worker burnout event rivaling the black plague at a drag strip. Just one year after publication, COVID-19 ushered in the worst, longest, darkest season of overwork, stress and burnout the healthcare industry has seen in a century.
And with the industry marching predictably toward Value-Based Care, onboarding a new clinician comes with a massive learning curve. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.
Add to it that none of this HCC coding was taught in medical school, and you have a perfect storm that even Clooney & Wahlberg would struggle to make sexy.
Why do they make it so hard?
The rising tide of burnout and the steady growth of VBC and HCC coding knowledge form enough of a riptide of impossibility for today’s practitioners. But the teaching methods being used to bludgeon new codes into the weary minds—and workflows—of new residents and established docs alike are downright cruel. Consider that HCC coding education is being deployed using some of the most arcane and ineffective teaching tools available today.
1 hour seminars are the lingua franca across nearly every provider group in a risk payment model. And if sitting in a classroom being talked at while pretending not to stare blankly at your phone was not bad enough, the two worst years in most providers’ careers were met by shifting those interminable seminars to a Zoom call, probably on your phone.
Consider the vital role that HCC coding plays in capturing critical diagnoses to be treated, documenting those diagnoses to keep them treated, and billing against Risk Adjustment scores to reimburse for essential healthcare services that keep patients out of the hospital.
And we are teaching these skills over a Zoom call? With providers more burnt-out than ever, and Zoom fatigue at a universal high – we are lecturing doctors on HCC coding over their phones? Is it a surprise that engagement is low? Is it a surprise that errors are high? Or that adoption of full risk models is sluggish at best?
And yes, one-to-one coaching is the gold standard, and those who provide this mission-critical service should be heralded in the streets and welcomed with ticker-tape parades. This is heroic work. But with global workforce shortages, there are definitely not enough coaches to tackle the task at hand. Not for all the clinicians in desperate need of a rapid increase in their fund of knowledge on VBC and HCC coding.
Is there really no other way?
Full disclosure: this is a blog post by a brand that has pioneered another way to teaching HCC coding to doctors. And it really works. But we are not here to sell you our solution. At the moment, we are only here to say as loudly and as clearly as we can that Ye Olde Ways™ are not working. And if there is a better way—which there is—we need to be running toward it like actual lives depended on it. And not just patient lives – doctor lives, nurse lives, NPs and PAs and coders and operators and the IT team, too. There is a lot at stake, and it’s time to search for answers.
If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most.
Looking for a quick HCC coding knowledge hack? Use this Quick Guide to identify HCC codes for risk adjustment. Diagnosis coding for value-based payment models is one of the key drivers for innovation in modern healthcare – aligning incentives with care in ways that were only talked about in decades past. However, without appropriate and deep HCC coding knowledge, properly documenting chronic conditions that risk adjust is simply not possible.
The need for HCC coding knowledge continues to rise, from ACOs to ACO REACH and to payors and groups in VBC contracts with varying degrees of risk. The CMS’s Alternative Payment Models (APM) increasingly require clinicians to have more than a basic understanding of HCC coding – mastery is becoming the industry standard. Mapping ICD-10 codes to HCCs (Hierarchical Condition Categories) is more than a simple conversion, knowing when and where to use which codes—and how to document accurately–is vital.
And while we advocate for tools that increase the fund of HCC coding knowledge across all relevant clinicians, we also know that your team almost certainly needs a quick-fix that can be deployed today.
You must be able to diagnose the severity of your patient population’s illness in order to accurately and effectively provide care. Obviously, there is an ROI discussion to be had around lost revenue for under-billing for sicker patients. But the bigger risk is under-caring for those patients, and failing to avoid preventable visits to the “expensive care” department.
And while there are those who believe that HCC coding should be in the bailiwick of coders, and clinicians should stick to treating the patients, most modern doctors understand the complex interweaving of the relationship between practicing medicine and following protocols. Diagnosing with a deep understanding of HCC coding and its impact on RAF scores and patient outcomes is an essential component of the modern doctor’s toolkit.
One key piece of that toolkit is a modern approach to HCC coding education, such as what you’ll find in the DoctusTech app. But for today’s lesson, we’re going to give you the shortcut – our HCC Quick Guide, free download.
“We have found that by using a simple workflow intervention and tool, physicians can ensure that their diagnosis coding is informed by HCCs and optimized for payers’ risk adjustment calculations.”
Obviously, we’re biased as to which workflow intervention tool physicians should be using. But before deploying a tool inside the EMR, physicians must be educated on HCC coding – and the old ways are simply not working. So if you need a quick fix, get our Quick Guide. And if it’s time to look into a real solution to cut onboarding times, and get physicians engaged in learning HCC coding and documentation, maybe it’s time to look into more than a quick fix.
And as you identify which chronic conditions have HCC codes that impact risk adjustment, documenting those correctly in the patient’s chart is an important next step. BUT, even if your team is capturing the appropriate codes, but not appropriately documenting, that diagnosis and the dollars earned against it are itching for a bad time. Not only is CMS bringing audits, the DOJ has increased scrutiny on VBC contracts and is incentivizing whistleblowers. This is no longer an area where you can get by on good intentions.
In VBC, not every chronic condition contributes to risk adjustment, so look for those conditions are weighted for risk adjustment – these will be the ones that require more costly care. Don’t rely on the EHR to do this for you, HCC coding knowledge is critical.
Our HCC Quick Guide can help you as your team dips toes in the water, but again, today’s clinicians badly need a deep and growing fund of knowledge on which diagnoses map to HCC codes, which contribute to risk adjustment, and how to document them.
Download the HCC Quick Guide now – print and post it, carry it, laminate it! This will be a vital tool as you lean into risk adjustment
Practicing in value-based payment models requires clinicians to diagnose and document all appropriate chronic conditions that contribute to Risk Adjustment Factor. Each condition must be documented and readdressed annually. This is a critical piece of the annual wellness visit, and any further appointments.
You cannot treat what you don’t diagnose. And you cannot bill against poorly documented diagnoses that have not been properly HCC coded. And you don’t get paid to treat conditions that do not contribute to Risk. So when you put that all together, HCC coding education should be a central component of your team’s toolkit.
It has long been thought that the machinery of the US healthcare system is so big, so complex and so established that steering the ship is nearly impossible. However, if we’ve learned anything from the COVID-19 pandemic, we can be nimble when we have to be. Lives were on the line, the nation itself was at stake, and The Industry dodged and weaved as nimbly as an NFL receiver. Truly, the entire industry adapted in ways that would have been called impossible a year earlier. Legislative and commercial interests flexed to co-author solutions that feel second nature today – so we know it can be done.
Enter Value-Based Care.
The market shift toward VBC has been slow, but for such an unwieldy thing to shift at all, it has been meaningful in its steadiness. The market is truly moving toward value. We recently blogged on the annual dollars paid in each model, from FFS to full risk, and the trend is a steady annual march. (Read that full blog here: The Rise of Risk: Value-Based Care Payments Increasing Year Over Year
The challenges and opportunities inherent in any change are perhaps more significant, as literally millions of lives hang in the balance. If the nation shifts toward VBC, the sick and aging have a much better chance of receiving better care. One study found that full-risk payment models correlated to a statistically significant decrease in avoidable hospitalizations. (Read the full report here: VBC: Full Risk Shows Lower Preventable Hospitalizations of MA Beneficiaries, Study)
Rather than the high volume-based rewards inherent in the fee-for-service model, value puts the revenue on the other side of patient health, rewarding better results in quality, outcomes, and costs.
But is this good? The CMS has made it clear that their goals for 2030 are a massive shift toward VBC, even though many of the benefits of the model are still largely theoretical. And documented benefits of organizations currently operating in VBC contracts—with either shared savings or varying degrees of risk—have even been deemed untrue, or correlated through dubious means like selection bias. And to be sure, some programs have favored less sick patients to avoid the risk of costly visits to the ED.
But overall, the benefits appear to be demonstrably there – and the industry is shifting. Glacially slow, sure. But shifting all the same.
And while some parts of the industry shifts, there are also vast swaths of healthcare that are so deeply entrenched in fee-for-service that they may never move. And maybe that’s not such a bad thing. After all, if there was no darkness, how would we know to be grateful for the daylight?
And so the industry gradually shifts toward value. Investors in the for-profit side of the business of health are taking notice of the ROI in well-run VBC programs. And conscientious investors are becoming more committed to the humanitarian side of wealth, urging boards to take a risk on risk in the interest of improved patient outcomes. And even the most pecuniary of fiduciaries are inclining toward value as the revenue cost-justifies the risk when things are done right a risk adjustment.
And yet, there are organizations that simply refuse to budge – and maybe never will shift to Value. And the reluctance to shift is almost reasonable. VBC incurs significant startup costs, and FFS pays pretty well. Why rock the boat? In a nearly even split between risk and FFS (40% / 40%), there is not yet enough market pressure to force the change.
But will that day come? Will the US consumer eventually learn about value-based care, and start to demand that providers and payors align their financial gains with patient outcomes?
Will legislation force or speed the shift?
Or will there always be fee-for-service as an unavoidable piece of the US healthcare system? And is that such a bad thing?
As we help organizations streamline their shifts into profitable VBC programs through our HCC coding education for doctors and our EMR integrated platform, in many ways, we are also watching from the sidelines.
And while some still say the jury is out, we’ve seen enough from the inside of some of the best operators in VBC to know that the case is closed. Sure, there is plenty of room for improvement. New legislation and increased scrutiny continue to make the compliance piece daunting to the uninitiated. But whether you’re operating the old FFS model, shifting toward VBC, or in it to win it, it’s more clear now than ever that Value-Base Care is the future, and it’s time to make the shift.
Got questions? Curious about the tools and resources required to raise RAF accuracy, boost diagnostic specificity, and lockdown documentation? Need your doctors to learn HCC coding yesterday? We get it. Value-Based Care is important, but it can also be incredibly complex and difficult.
The US healthcare market is leaning in the direction of Full Risk Value-Based Care. While the system is often characterized as a monolith; a massive, unwieldy machine (and as immovable objects go, it is a big one), that big machine is trending steadily toward full risk value-based care.
The CMS recently reported that total spending reached “$4.1 trillion or $12,530 per person [in 2020]. As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7 percent…” That’s one out of five American dollars. And somehow, with all that money on the table, we still struggle to improve outcomes. (Source: CMS)
According to OECD.org, of the 38 member nations, The US spends more per-capita on healthcare than any other member nation. Also, our already lower-than-average life-expectancy took a higher-than-average hit from the pandemic. “The United States recorded the largest drop in life expectancy of any OECD country during the pandemic, falling from 78.9 in 2019 to 77.3 in 2020 – a decline of 1.6 years, compared to 0.6 years on average.” (Source: OECD)
With the US staring down these and myriad other daunting data points, this is an ideal time to chart a path forward, up, and out of the quagmire of fee-for-service stagnation. Thankfully, change is coming. As we recently posted in our blog, the total dollars of US healthcare spending are gradually shifting away from FFS, through Quality, and into risk models.
CMS Innovation Center has stated that its Goals for 2030 are that all Medicare and the vast majority of Medicaid beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030. They aren’t specifically stating the “full risk model” as their 2030 goal, but that is the trend and a worthy goal.
And on the topic of trends, doctors increasingly favor full-risk payment models. While educating clinicians—without the right tools—can be a daunting task, more and more clinicians are moving their small practices into full risk value-based care contracts. And while engagement is tricky without the right resources, doctors are consistently in agreement that the incentive alignment inherent within a full risk model is moving the business of medicine in a direction that validates the same noble reasons that compelled them into medical school: patient outcomes. And so long as doctors are supported with access to engaging and impactful HCC coding education, the transition to full risk will continue.
Why is Full Risk Value-Based Care growing, year over year?
As mentioned above, doctors practice medicine for one very simple reason: they want to help people. And while the past century has focused heavily on healing sick people, full risk value-based care models are empowering doctors to achieve an even nobler goal: to keep people healthy. And while pulling a sick patient back from the brink certainly has its thrills, real job satisfaction is found in keeping patients living stable, healthy lives – far away from the avoidable acute events that would have sent them to the ED.
Why do doctors care about Full Risk in Value-Based Care?
When the financial incentives align to incentivize better outcomes, or put another way, healthier patients, one product of that machine is a steady stream of happy doctors. The business goals agree with the doctors’ goals. And with the advent of better clinician HCC coding education tools, engagement is on the rise. And engaging with the tools to improve specificity and accuracy in diagnoses puts clinicians at the forefront of change. The more they engage, the more they learn; the more they learn, the better they diagnose; the better they diagnose, the more they can impact patient health before an avoidable acute health event occurs. Simply put, improving clinician engagement on HCC coding directly impacts every bottom line. ROI improves, ability to deploy more preventative measures improves, patient health improves and physician satisfaction inevitably rises.
What is slowing the transition to Full Risk in Value-Based Care?
Inevitably, there are blockers. As they say, no good deed goes unpunished. And it’s incredibly hard to move a massive machine – especially one that comprises one fifth of the nation’s gross domestic product. And frankly, much of the for-profit side of healthcare is resistant to a move away from fee-for-service. That model has grown the revenue streams of many massive corporations, whose shareholders are opposed to not-making-money. And whose leadership has a fiduciary responsibility to those shareholders to keep making money. And while Full Risk in Value-Based Care does show strong ROI, that revenue comes with strings—and risk—attached.
“There is activity in value-based care, but what we see as the biggest challenge is provider engagement… Providers need to understand how to be successful in value-based arrangements.”
— Dr. Andrei Gonzales, assistant vice president of value-based payments for Change Healthcare
The Department of Justice released an analysis of all False Claims Act settlements and judgments in the fiscal year 2021, and healthcare was the source of 5 out of 6 BILLION dollars in settlements and judgments. (Read more on our blog HERE and HERE) Medical fraud took the top line, but Medicare Advantage abuses like upcoding and over-coding—diagnosing conditions that were not in the chart—came in close behind. And these cash-grabs are only the ones that were caught – but they represent enough of a red flag that CMS, the DOJ, and the OSI are all looking very hard at recent changes in payment models. And a RADV audit is no longer the bogeyman exclusively haunting payors. In an effort to restore public trust and recoup misspent healthcare dollars, the Department of Justice and a host of other agency audits are increasing every year. And with whistleblowers rewarded up to 30% of the significant financial judgments, every employee stands to become a robber-baron just for speaking up. In effect, taking a massive cut of the ill-gotten gains.
Dr. Andrei Gonzales, assistant vice president of value-based payments for Change Healthcare said, “There is activity in value-based care, but what we see as the biggest challenge is provider engagement… Providers need to understand how to be successful in value-based arrangements.” (Source: ModernHealthcare)
Educating doctors is not an easy thing. Even Hippocrates himself required future doctors to vow to teach his children how to practice medicine if they cared to learn. Because with the ever-evolving fund of knowledge required just to stay in the stethoscope, the challenge is steep. And for modern providers, the ask is bigger than ever. But it does not have to be like Sysiphus, pushing his rock uphill every day, only to watch it roll back down again. Thankfully, with modern HCC education platforms like the DoctusTech app and integrated tools to drive engagement, today’s doctors have the potential to learn HCC coding faster and more deeply than ever before.
And the faster physicians can learn HCC coding, the faster we will see the industry shift toward to Full Risk in Value-Based Care. And while it may not be a panacea for all that ails the US healthcare system, the transition toward Full Risk in Value-Based Care is the single best way to align incentives, ease the clinician workload, improve outcomes and decrease costs.
Want to try teaching HCC coding to your doctors in a way that really works? No more zoom calls, no more email blasts – a truly engaging platform with proven results. Demo the DoctusTech app today – your doctors will thank you. The ROI from your risk contracts will thank you. Your patients will thank you. And you will help the US take a critical step toward Full Risk in Value-Based Care that actually works.
Specificity and accuracy are the keys to any successful Value-Based Care program. And clinical vignettes are a great way to learn.
Five years ago, the AAFP (American Academy of Family Physicians) published a crash course to educate family physicians on HCC coding. To this day, the clinical vignettes from this family physician HCC coding education course are still a great example of how and why family physicians need to diagnose specifically and code accurately in order to fully capture and treat the actual needs of their patients.
So if you are trying to educate family physicians on HCC coding, this Crash Course is a great place to start. As always, the M.E.A.T. criteria must be met in order to properly diagnose and accurately code any diagnosis.
And here are the clinical vignettes presented in the AAFP’s HCC Coding Education Crash Course for Family Physicians:
Risk Adjustment Scores vs. Optimized Risk Adjustment Scores in Common Primary Care Encounters
Family Physician HCC Coding Example #1
Patient with DM II presents for routine follow-up. A1C 8.3. Also has stable COPD, oxygen dependent. O2 DME papers signed earlier this year.
Chronic Resp Failure w/ hypoxia
DM w/ hyperglycemia
Total optimized risk=
Family Physician HCC Coding Example #2
68 y/o patient with hypertension and hyperlipidemia and BMI 37.2. Has been using CPAP for years.
Total optimized risk=
Family Physician HCC Coding Example #3
Patient with diabetes and polyneuropathy. Right great toe amputated several years ago. He continues to smoke. Patient brought in multiple records from other providers. In addition to refill of meds, you counseled for 5 minutes regarding smoking cessation. You spend 35 minutes reviewing and summarizing the outside records and include that in the visit note.
DM w/ polyneuropathy
Acquired loss L great toe
Total optimized risk=
Family Physician HCC Coding Example #4
Patient with HTN comes in for upper respiratory infection. Remote history of colon cancer and now has a chronic colostomy bag. DME orders signed earlier in the year.
Upper Respiratory Infection
Upper Respiratory Infection
Total optimized risk=
Family Physician HCC Coding Example #5
76 y/o presents with swelling of the left arm, redness, and pain. He takes warfarin for atrial fibrillation. He is also a liver transplant patient. Given IM ceftriaxone. PT/INR and CBC ordered.
Cellulitis of L upper ext
Cellulitis of L upper ext
Long term anticoag therapy
Liver transplant status
Total optimized risk=
Family Physician HCC Coding Example #6
Patient for follow-up of major depression, improving. New med started 6 weeks ago.
Major depression, single, unspec
Major depression, single episode, moderate
Total risk= .000
Total optimized risk=
When educating doctors on HCC coding, be sure to avoid common HCC coding pitfalls by remembering these rules:
• Use documentation and coding to capture the severity of illness/risk of high cost
• Make sure that you capture the complexity of the patient
• Major issues need to be captured at least once a year (clock restarts Jan. 1)
To access the full AAFP HCC Coding Education for Family Physicians Crash Course, Click Here.
Need a real solution to train your family physicians on HCC coding for value-based care?
While this crash course is a great place to start, family physicians prefer to learn HCC coding and documentation for Risk Adjustment in the DoctusTech HCC coding education app. It is the only tool that consistently ranks #1 with both physicians and operators. Demo the app today.
Requiring clinicians to learn one more thing—especially when HCC coding does not feel connected to treating patients—is a big ask. Expecting them to learn in ways that are both ineffective and profoundly dull is just plain cruel.
Doctors talk a lot about behavior change in patients. But behavior change in doctors is incredibly tricky to effect. But to make Value-Based Care actually work, behavior change has to happen at the clinician level. Is it any surprise that asking doctors to sit in a classroom (or on a Zoom call) for an hour to be lectured on HCC coding is both wildly unpopular and not actually effective?
The importance of clinicians mastering HCC coding cannot be overstated. Without proper coding and documentation, Value-Based Care will fail. So we need doctors to understand Hierarchical Condition Categories: how to use them, when to use them, which ones to use and for what. And ultimately, why.
You cannot treat what you do not diagnose.
(And you cannot diagnose what you do not document.)
(And you cannot document what you don’t know.)
While we acknowledge that HCC coding lectures do result in limited initial behavior change, doctors inevitably regress back to the mean. They return to doing what they already know.An email blast with the code of the month has even less impact than a lecture. And even the “gold standard” of one-to-one coaching returns a much smaller lasting impact than the time required to conduct the coaching.
Onboarding a new clinician with zero HCC knowledge can be as daunting as moving established providers into Value-Based Care arrangements.
So what is the answer? If the gold standard only makes a small dent in the needed fund of knowledge, and classroom learning is only marginally effective at short-term behavior change—and email blasts are worth less than the paper they’re not printed on—is all hope lost?
Please allow me to introduce you to the DoctusTech HCC Coding Education App.
Five reasons you should try this app for your team:
Do something different. If you are doing what the rest of healthcare has done for years, your approach is not likely to be any more effective. Ask your CDI team. Ask your doctors. Ask your Director of Quality. It’s time to try something new. Our app teaches HCC coding in a new, fresh way that doctors actually enjoy. We use the socratic method, the same technique used when studying for boards: clinical vignettes.
Timing matters: act fast, learn fast. By not embracing HCC coding fast enough, your VBC contracts are not generating the revenue they need to. And in order to support clinicians and patients, you need to learn and adopt – faster. The in-app lift requires less time than microwave popcorn, per week, and delivers real-world behavior change right away. Our app is fast.
Money matters. Patient care is directly related to revenue. Revenue is directly related to RAF accuracy. And RAF accuracy is downstream from HCC knowledge. Invest in your clinicians, change behavior, capture and document new diagnoses, boost RAF accuracy. It all starts with changing the behavior of your doctors. Our app changes behavior.
Happy doctors practice better medicine. By using a tool they enjoy, and driving results right away, your doctors will thank you. Our app has a 90+% month-over-month engagement rate across all clients. Our app makes doctors happy.
25 Hours of CME. Learning HCC coding in the DoctusTech app is not only fun and rewarding, it also provides 25 hours of accredited CME per year. So if you are asking your doctors to learn HCC coding, give them the tools they need to succeed, along with a nice 25 hour CME bonus on the side. Our app provides 25 hours of CME.
In Friday’s “State of the Department” address, HHS Secretary Xavier Becerra spoke candidly about upcoding and overcharging in Medicare Advantage. After offering prepared remarks on the continuing COVID public health emergency, Robert King of Fierce Healthcare asked very pointedly about upcoding in Medicare Advantage. Secretary Becerra answered with few specifics, but a clear directive that upcoding, overcharging and costs within Medicare are very much a priority of the department.
“All those things are being examined…
We’re going to get our money’s worth for Americans.
– Xavier Becerra, HHS Secretary
>> Robert King: Hi, Robert King with Fierce Healthcare. Thanks so much for taking my question.
I want to talk to you about the Medicare Advantage program, which has grown a lot in popularity, but it has undergone criticism from progressive lawmakers about risk adjustment tactics like upcoding, which is leading to Medicare overpayments.
Do you share those concerns? And if so, what actions is HHS doing to kind of alleviate these issues?
>> Xavier Becerra: Robert, great question, and thanks for asking a question that seems to be a little bit different from some of the others.
So, Medicare Advantage started as a program where we were told by the plans that are offering Medicare Advantage that they could provide as good a level of services health care to seniors on Medicare as the existing traditional system of Medicare, what we call a fee for service, but for a better price.
So it was going to be a good deal for Medicare recipients to have access to good health care services through a Medicare Advantage plan, and it was going to be a good deal for the taxpayers because we would save money in the process.
So far, from what I understand in the evidence, the data, it shows that we spend more per Medicare recipient through the Medicare Advantage program than we do through the fee for service program for Medicare recipients.
We have seen some evidence that in certain areas there seems to be charges that go beyond what would be necessary.
You mentioned the upcoding, which means that a provider will say that they provided a service that is greater or more intense than what was actually needed by the patient, and therefore they get a higher level of reimbursement.
All those things are being examined. There is clearly evidence out there on a lot of these things, and we are taking a close look at how we can make Medicare, writ large, work for Americans and for taxpayers.
We’re going to get our money’s worth for Americans.
We want to make sure that every American senior, every American who receives Medicare, gets what they deserve. Americans work really hard for their Medicare, and so we want to make sure it’s there for them. We don’t want anyone overcharging seniors or any other Medicare recipient for services, and we don’t want taxpayers to be duped.
And so we’re going to do everything we can, whether it is Medicare Advantage or Medicare fee for service to make sure that we’re getting our money’s worth.
And with that, Secretary Becerra concluded the press conference. While no specifics were given as to just what exactly HHS and Secretary Becerra have planned, it’s clear that the concerns about upcoding, overcoding, and overcharging in Medicare Advantage are clearly in their sights.
CMS recently unveiled their replacement for the Direct Contracting Model (DCE), renamed now as the ACO REACH Model. Many of the original Direct Contracting Model tenets will remain the same, with a few significant changes announced.
From heightened scrutiny on up-coding and documentation accuracy to improved Access and Equity, the new model looks to improve upon DCE without replacing it entirely.
Download the full CMS webinar presentation deck, and read our interpretation of the new guidelines.
Levi Wiggins: Alright. Here we are. Live with Dr. Kazi for Year End Preparation for 2022: things to stop doing, things to start doing and things to keep doing. Our host, as always, is Dr. Kazi. Give us a brief introduction!
Farshid Kazi, MD: Thank you everybody. Farshid Kazi, internist by training, with a palliative care focus, then hospitalist, outpatient doctor, and kind of grew up in the value-based care system. And now I’m here with DoctusTech.
Levi Wiggins: All right now, I want to jump right in. So we’re going to start with things to stop, what to start its place. And when we get to the end, we’re going to talk about some things to continue.
So the first bad habit of VBC and HCC documentation to break in 2022 is the 60 minute lectures once or twice a year – stop doing that. But why Dr. Kazi?
Farshid Kazi, MD: Uh, other than the fact that they’re mind-numbingly boring, and as we all know, we don’t actually retain the information. The data is very clear that doctors don’t have sustained behavior change from it. So if you think about your attention span, post-college, I’m assuming most of you can’t sit and listen to a lecture for 60 minutes anymore.
Nobody can, so why do we keep doing it? Because it makes us feel good. We should stop doing it, call it for what it is. Let’s find a better way to meaningfully engage doctors, teach them about this information, and then hold them accountable. And what that means can vary by organization. It can mean that you’re running some type of test to make sure knowledge retention is happening.
You can do one-to-one coaching, which is still a very meaningful way to give feedback to your docs. But please, please stop doing the one hour lectures—for the sake of your doctors—and start holding them accountable for real knowledge retention through one of many ways. And DoctusTech is one of those as well.
Levi Wiggins: Wait, so you’re saying the 60 minute lectures, just like they do in medical school (sarcasm)! Right? That’s how doctors like to learn, right?
Farshid Kazi, MD: Yeah. I mean, Levi, there’s no magic there, right? So you can teach doctors multiple different ways. Teach them with clinical vignettes. You can teach them with one-to-one feedback. You can even teach them by doing charts and dissections, but what you should not do is put them in a classroom setting for an hour and teach them about ICD 10.
Levi Wiggins: That sounds so boring. Alright. The next bad habit to stop as we roll into the next year: pre-templating notes for doctors with new diagnoses. “Here doc, I think you missed one!”
Farshid Kazi, MD: Yeah, we all do it. Any organization has a lot of different strategies on making it easier for doctors. We get it. Doctors are really busy. There’s a lot to do. But pre-templating notes, giving them the diagnosis, is really frowned upon by CMS and DOJ. And if you haven’t seen our white paper around RADV audits, you should take a look at it, because there really have been some slaps on the wrist saying, look, let the doctors do what they’ve been trained to do, make clinical decisions.
And that should not be by prompting from non-clinicians around new diagnoses.
Levi Wiggins: So the thing to start in place there, uh, improving physician workflows inside the EMR. Tell me more about that without a doctor’s tech infomercial. I’m warning you!
Farshid Kazi, MD: So when we think about how we make that easier for doctors, oftentimes we’re trying to do the work for doctors, but really that’s a heavy lift and the hardest solution. Fix the problem inside the EMR. Find a way to get the data that you have outside of your EMR, into the EMR, and solve for the issue, so that doctors can make clinical decisions while they’re with their patients at the point of care.
Levi Wiggins: Okay. And I’ll go ahead and make the infomercial being the marketing. We have a way to do that. So if you’re trying to break that bad habit, hit me up on LinkedIn.
The next thing is stop the checklists of claims-driven diagnoses without supporting evidence – or start getting in big trouble.
Farshid Kazi, MD: Again, the same slap on the hand that happens from pre-templating notes with diagnosis for doctors can happen when you start putting bad data in front of them. We all know claims data is notoriously noisy and inadvertently inaccurate. And so if you start to put inaccurate data in front of your doctors, hoping that they’re going to be a hundred percent accurate, you’re going to find yourself in a bad spot.
So really, starting to think of, “how do I get the right data in front of the doctors at the right time with meaningful support so they can make a true informed decision” is critical here as far to part of your accurate risk adjustment documentation.
Levi Wiggins: We do talk a lot about that checkbox culture, and that’s not why you help patients. You don’t want to check boxes. You want to help them.
Farshid Kazi, MD: You give the doctors a list of check boxes to go through. Their only mission is to get through that. It’s not to make sure it’s accurate. It becomes really a difficult task for them to do. But if you’re giving them insights, giving them clinical guidelines, and letting them do what they do best—which is make medical diagnoses and treat patients—they will optimize their documentation and it will optimize your risk adjustment score accuracy.
Levi Wiggins: So the start on that is to make more of an effort to get supporting documentation and then provide it to your doctors with any claims data. Does that sound about right?
Farshid Kazi, MD: That’s absolutely right.
Levi Wiggins: So when we look at these organizations that are really forward-thinking, they’re kind of where everybody wants to be. There are a few things we see that they’re doing. And if your organization is doing this, first off, I want to commend you – because you guys are doing the hard work of making this easier for the doctors. Thank you. You guys are heroes.
Ok, of the things to continue in 2022 internal audits. I know you hate it, but there’s so much better than an external audit.
Farshid Kazi, MD: Tell me about it. Yeah, gone are the days of just trying to increase your RAF. That should never be part of the nomenclature. It should not be the talk talk-track for any of your teammates. Really, you need to be thinking about how to make your documentation accurate.
Not only for increasing the proper diagnoses, but looking for inaccurate over-documentation. It happens inadvertently. It happens in every organization and, some of the data is showing somewhere between 5% and 15% of data submitted is inaccurate. So starting to look both ways and telling Medicare, CMS, DOJ: we are doing our best to make sure we’re documenting accurately.
And that’s because we are internally auditing for anything that is over-coding. Give the money back before you ever receive it. So you don’t get into trouble.
Levi Wiggins: That’s absolutely right. And, and it’s partly just an ethical thing. Partly it’s an administrative thing, but for those of you who are doing those internal audits, you guys are true heroes.
Levi Wiggins: OK, the next thing to continue for 2022 is accountability for your doctors!
Farshid Kazi, MD: Yeah, too often, we start to, to spread ourselves thin. Everyone’s doing everything. It’s a team approach, but really, who’s going to be held accountable for the knowledge game? How do we make sure the doctors have retained information to be accurate and compliant with their documentation?
We need to show some type of effort and accountability. And again, thinking through this is not easy to do, transitioning from a fee for service model to value-based care requires a massive change – and dovetails into a few other things that good practices are doing. But really, having a tracking dashboard, showing that it matters.
And then giving feedback to your doctors is critical around that.
Levi Wiggins: Now this one, to be honest, I don’t really know what this means. What I want you guys to continue is time allotments and you and I are both going to find out what this means now!
Farshid Kazi, MD: Documenting accurately takes some time. And so if you’re going from a predominantly fee for service driven model to a value-based care driven model, you need to get C-suite buy-in to have commitment on increasing time of visits, giving doctors time to document accurately. So they’re not trying to get done quickly, working in the car, at home on the weekends, or even worse – while they’re with family.
It’s giving them time to document accurately and change the schedule – it has to be done with intentionality. You cannot fit the same model of value-based care into fee for service and expect something totally different when it comes to outcomes.
Levi Wiggins: Oh, that makes perfect sense!
OK, the last thing we have for those of you who are doing it, continue, keep up the fight! And for those of you who are not doing it, this is the year to make those changes. Clinically driven ROI. Over to you, David, in the studio!
Farshid Kazi, MD: Levi, too often risk adjustment documentation accuracy is around financials. It’s about the numbers and the dollars coming. Why does that matter? The mission behind value-based care is we’re trying to help reinvest into delivering better outcomes.
And so if you do your documentation accurately, you can invest in the palliative care, you can invest in the tele-health, or remote device monitoring. So show your doctors how that capital is being repurposed towards improving patient care. And all of a sudden you will see buy-in and commitment.
I am a big believer that my colleagues are trying to do the best for their patients, but the infrastructure… The healthcare system was not built to help them succeed. So as you make this transition, if you start to show how you’re reinvesting those dollars, it will have a meaningful impact for your doctors.
Levi Wiggins: That’s great! Now, forgive my naiveté here, but I know we encounter organizations that aren’t doing some of these things. And to me, you know, I’m just over here in my office, doing my own thing. Help me understand why some organizations aren’t embracing these things, they should start still doing the things they should stop.
Is it, is it budget? Is it time? Is it sloth and human frailty? What is it? Lack of resources? What’s what stops an organization from doing the things they should do – this list that they know they should start and stop and continue?
Farshid Kazi, MD: Can I say, all of them, Levi? Is that a cop-out answer? I mean, it could be any number of those, right? But there’s no question. If you look at this list, things we’ve talked about, they should be hopefully obvious and things that you should do. And yet 80% of the groups we talk to do some combination of the things we’re asking people to stop. It’s clear as day that the DOJ has a high degree of focus on documentation accuracy, as does CMS.
And so, right now is the time to start thinking about how you stop this. You get your C-suite, buy-in have physician champions and try to do this the right way from the get-go.
Levi Wiggins: And this can all be done… every single one of these can be done without ever booking a demo of our tools, talking to us – like, you don’t need us to do this stuff, right?
Levi Wiggins: Obviously we help, we help automate a lot of these processes. Am I Canadian? I just said “PROcesses.” So I’m probably Canadian. Anyway, we do make it easier, but they can do it without us. Right?
Farshid Kazi, MD: A hundred percent. The purpose of this is so that it makes you feel a little bit uncomfortable and saying, Hey, let’s try to do 2022 better.
And yes, we, a hundred percent can help. And that’s why we built DoctusTech, but you don’t need us. You don’t need a vendor to do this. You can really start to do this with the resources you have without spending a single dime.
Levi Wiggins: But also, DoctusTech: solutions for people like you who need to stop doing things they did last year and do different things in 2022!
Levi Wiggins: All right. That’s a wrap! Ok, to sum it up, here’s the full list:
CMS released its final Medicare Shared Savings Program rule, called “Pathways for Success” for ACOs. The new rule is designed to help establish a path toward risk, with a heavy focus on Risk Adjustment Coding.
CMS = Centers for Medicare & Medicaid Services || MSSP = Medicare Shared Savings Program || ACO = Accountable Care Organization
MSSP lays out a clear transition to risk, and allows ACOs to start at different points, depending on where they are as an organization. Also, it extends the agreement period from 3 to 5 years, which provides more time to measure performance against the benchmark. This creates a Basic and Enhanced track option en route to risk. (See Image A below)
Image A Basic & Enhanced Tracks
There are several best practices an ACO can adopt to help succeed within the new model. Many ACOs are now looking toward Risk Adjustment which not only allows highlighting of high-risk patient populations, but will also provides a more accurate way of predicting cost and determining reimbursement.
The adoption of HCC risk adjustment best practices has been recognized by Medicare Advantage plans for several years. In contrast, ACOs who participate in Medicare Shared Savings Program (MSSP) have opted away from any type of program, as they felt it had little effect on their benchmark. This is often due to an ACOs past experience within the MSSP. However, the new changes open many doors to those who may have shied away from risk in the past, for reasons such as:
Benchmarks were based 100% on an ACO’s historical success.
No adjustments were made on the true risk score of the beneficiary, thus no penalty for similar low risk scores year over year.
False/inaccurate predictions of condition profiles of beneficiaries.
Re-enrolled beneficiaries given a demographic adjustment only, making it very difficult for an ACO to improve coding and increase benchmarks.
Given the new Pathways to Success Rule, ACO groups are being shown risk adjustment in a different light. There are no more restrictions on RAF changes for the historical beneficiary. Instead, there is a 3% limit on the total increase from historical to performance year.
ACOs continue to lag in adoption of HCC coding practices. From the most recent 2019 Shared Savings PUF file, 49% of groups have seen a drop in RAF from benchmark year 3 (BY3) to Performance Year (PY1). RAF scores on these groups dropped from 1.0149 within BY3 to .9819 in PY1 on average, showing a -3.25% drop (see below in Image B). As a result, ACOs could have faced a significant uphill battle over the next few performance years as they attempt to true up their future benchmarks. This is one significant issue addressed by MSSP.
Image B: RAF Decrease PUF file 2019 ACO MSSP
Coding improvements are capped at 3%, however, with this drop (shown above) from BY3 to PY1, RAF improvement can actually be significantly above the allowed 3% to offset the drop of -3.25%. Therefore, now is the time for ACOs to begin adopting HCC Risk Adjustment best practices to help in this effort.
By adopting best practices within HCC coding, you can ensure that your medical group has the highest specificity of diagnoses, ensuring quality of care and compliance.
What exactly are these best Risk Adjustment Coding practices that can be adopted?
Making correct preparations prior to encounter
Documentation of all chronic conditions that are current
Ensuring a clean clinical workflow to display conditions for clinicians
Post-encounter review for quality assurance
As value-based care is being adopted on a wider scale, the old model of Fee for Service payment is slowly dwindling. More time is being spent with a patient to treat all chronic conditions at the encounter is becoming best practice.
One of the major issues that medical groups contend with is the ability to use all relevant data to create an aligned clinical workflow that helps the physician recapture, diagnose, and reject any conditions which are inaccurate. A melee of data is combined in the form of claims data, RX data, member eligibility, historical diagnosis, and utilization. The ability to organize this data into actionable insights, clinical suggestions, and quality opportunities is a huge task for any ACO.
Here at DoctusTech, we can offer a solution to this issue…..
The AAFP is a great first-stop for information on Risk Adjustment and HCC Diagnosis Coding. And although this article is a few years old (2018), their take on HCC Diagnosis Coding for Risk Adjustment is both unique and extremely helpful.
First, they lay out what it is and how it works. Then they tie it in with IDC-10 codes and HCC coding, to paint—with a broad brush—the full picture of what a practice will need to know, do and master to step into a risk adjustment payment model.
Mapping ICD-10 codes to Hierarchical Condition Category (HCC) codes determines the severity of illness.
Risk-adjustment factors heavily into new payment models.
Physicians should report any diagnosis codes associated with chronic conditions that affect treatment choices, not just the diagnosis codes that describe why a patient came in .
Physicians should comprehensively code chronic conditions at annual visits, as RAF (patient risk) scores reset every year.
HOW RISK ADJUSTMENT WORKS
First it may be helpful to briefly review the connection between coding, risk adjustment, and payment. Risk-adjustment models assign each patient a risk score based on demographics and health status. Demographic variables may include age, gender, dual Medicare/Medicaid eligibility, whether the patient lives at home or in an institution, and whether the patient has end-stage renal disease. Health status is based on the diagnosis codes submitted on inpatient, outpatient, and professional claims in a calendar year. Certain diagnosis codes map to disease groups (HCCs). Demographics and HCCs are weighted and used to calculate a risk-adjustment factor (RAF) score. – AAFP
The author then compiled a series of examples of HCC coding options, and how to determine which codes to use. Full list of examples here.
COMMON CONDITIONS AND HOW TO CODE THEM
Family physicians can increase the accuracy of risk-adjustment scoring by focusing on capturing diagnosis codes for the conditions they see frequently. Electronic health record (EHR) systems can help by identifying diagnosis codes that carry an HCC weight, but most do not. A related article in this issue includes a reference tool that physicians can use to keep HCC codes and RAF scoring in mind when selecting diagnosis codes.
You need a highly effective HCC Coding Program. If you’re a physician group engaging in value-based care arrangements: coding and documentation accuracy should be your top priorities. And inaction on your part will result in immediate loss of revenue and exposure to heavy audit penalties.
Whether you’re building a program from scratch or already have a program in place, the top five strategies for a successful program include:
Clinician Education — One-hour seminars or “codes of the month” emails don’t work.
Concurrent Chart Audits — This is more than checking boxes in the EMR to drag and drop chronic conditions into the progress note.
Point-of-care Clinical Guidance — Contrary to popular belief, we doctors don’t know everything! We make mistakes, and we don’t always have time.
Data Analytics — It’s painful and sometimes daunting, but it doesn’t have to be. Focus on a few critical points below to help drive an effective program.
Accountability — It’s a team effort. No single person should be held liable to be commended for the results.
Let’s dive deeper into your HCC Coding Program.
CLINICAL EDUCATION FOR YOUR HCC CODING PROGRAM:
Clinicians, on average, retain 15% of any educational seminar you send them to after residency. Even with 15% knowledge retention, there is a consistent regression to the mean after eight weeks. Out of sight, out mind!
No one size fits all, but we know the Socratic method of teaching, consistent education, and regular feedback result in sustained behavior change amongst clinicians.
Socratic method —
Stop teaching at doctors and start objectively testing their knowledge. Try clinical vignettes in small group settings. Problem-based learning is how most medical education is practiced today, and yet, coding education has not caught up. Customize training to your clinician skill sets and practice patterns to improve buy-in.
Consistent education —
Training is done once a quarter or via email will consistently fall flat. Clinicians have a lot going on, and to cement, any new information must be presented to them multiple times and in various ways. This doesn’t have to be time-consuming but does need to remain consistent.
Regular feedback —
We, clinicians, don’t like to be wrong and always strive to be better. So customized feedback on documentation accuracy and opportunities for improvement are critical. Moving away from clinic-based or team-based results. Make sure each of your clinicians knows their strengths and weakness as it compares to the group.
Clinicians, on average, retain 15% of any educational seminar you send them to.
CONCURRENT CHART AUDITS:
This will assist you to impact in 2 ways: A) Ensure compliant documentation B) Adjudicating any claims submitted.
A typical clinical documentation improvement program ensures correction of over-and-under coding before billing. Typically institutions “hold” a bill for two business days to make any corrections. During this period, the provider can be asked to clarify inaccurate documentation and adjudicate the superbill to ensure proper 1:1 matching with progress notes to billable codes. Much of this is currently handled at the payor level for smaller physician groups.
As you start to take on more risk as a physician practice, you’ll need a consistent strategy across all your payor contracts. While vendors are currently using a heavily manual process, emerging technology from DoctusTech will help you do this at the point of care with our A.I. This will drop your OpEx, decrease your risk during RAD-V audits, and give you a more accurate line of sight to your risk scores.
POINT OF CARE CLINICAL SUPPORT IN YOUR HCC CODING PROGRAM:
Doctors were not trained as coders, and coders were not trained as doctors. The basic premise of accurate documentation is and should be clinical. Clinicians need to take better histories, perform more accurate physical exams, and synthesize data to make clinical diagnoses. No coder or AI can replace and find these diagnoses as the data is inherently flawed with significant gaps.
DoctusTech can help doctors ask better questions, perform accurate exams, and present clinical guidelines to lets doctors practice medicine. This will inherently improve your RAF accuracy and create physician buy-in better than any Natural Language Processing or A.I. alone. Unfortunately, EMRs are limited by their data sets. They operate only off the information inputted, so if your PCP doesn’t have the complete clinical picture from your hospital systems and your specialists inputted into the EMR, the clinical decision support in your EMR will be lacking.
No pilot would fly a plane without an operational dashboard, so why do we allow the same for such a critical part of our value-based care business? No excuses, no delays. The ability to aggregate data from outside your EMR, deliver individual physician report cards on HCC documentation, and having visibility to patient annual wellness visits (AWVs) for everyone on the team is critical. If your team doesn’t have bandwidth, vendor it out. Time is critical, and the ROI is clear.
Remember, if the data is not easy to fetch and easy to understand, no one will use it. This does not need to be an expensive endeavor. Make sure you have visibility to the following data points by an individual physician.
Suspect vs. chronic diagnosis by patient
Complete vs. incomplete AWVs
% conditions addressed by a physician at each visit
Whether you plan to use a stick or a carrot approach to accurate documentation, the strategy needs to be intentional and meaningful. The entire team plays a role in an effective program, and accordingly, the strategies you deploy should touch each individual team member in a meaningful way. Rewards do not need to be financial, and the motivation here is it drives better clinical care. The emphasis in the following areas are compliant and effective:
% AWVs scheduled
Regular engagement with any coding tools
DoctusTech’s proprietary A.I. can be embedded into your EMR or on your mobile phone to help you complete steps 1,2,3,4 very effectively. All you have to do is be ready to hold your team accountable.
What is HCC coding? HCC stands for hierarchical condition category. It is a risk-adjustment coding model exclusively designed for estimating future healthcare costs for patients. The process of HCCs medical coding started in 2004, but it recently gained popularity due to payment models shifting from fee-for-service (FFS) to value-based care (VBC) arrangements.
Fig 1. Out of 70,000+ ICD10 codes, approximately 9,500 ICD10s map to a hierarchical condition category. Each HCC ICD10 is subsequently bucketed into 86 individual “condition categories.”
Fig 2. Each of the 9,500 HCC codes are put into one of 86 condition categories. Each condition category carries a specific RAF. No matter how many ICD10 conditions a patient has in the same category, they will only be assigned the RAF score one time.
Medicare assigns a risk score known as a risk adjustment factor (RAF) to each of the 86 individual condition categories. RAF scores of patient populations are subsequently used by Medicare and other payors to predict the cost of care, which influences reimbursements.
For the remainder of this article, we will explore the rationale behind HCC coding and why all providers (even those NOT in a value-based care arrangement) should care.
Why should doctors care about HCC coding?
HCC coding is the cornerstone of most value-based care arrangements. Today, “value-based care” is used synonymously with Medicare Advantage, but in the near future, we believe all forms of reimbursement will be tied to some VBC arrangement.
HCC coding falls under the broader term of risk adjustment (RA) models where patient care is paid based on a prospective payment model. Specially designed RA models are used to determine risk scores for patients. In the Medicare Advantage world, these models use the demographics and HCC diagnoses of the patient to assign a risk score known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.
This prospective payment model based on RAF does 2 things:
1. Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.
2. Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.
As Medicare and payers alike are starting to take notice of #1 and #2 above, the market is now trending towards building in value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.
HCC coding is here to stay and will only grow in the years to come. While the market has heavily leveraged medical coders or third party vendors to do much of the lift thus far, V2 of Value-based Care will require all clinicians to understand and participate in it for every patient visit.
HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. In our next 2 posts, we will dive deeper into the financial implications of HCC coding, HCC coding tools, and the clinical outcomes associated with VBC in 2021.