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.
“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.
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.
The Office of Inspector General is cracking down on Medicare Advantage prior authorizations that were denied which would have been approved under fee-for-service Medicare rules. Excerpts from the OIG Medicare Advantage prior authorizations denial report follow, quoted in full, arranged for clarity, and followed by our comments.
The OIG audited “a stratified random sample of 250 denials of [Medicare Advantage] prior authorization requests and 250 payment denials issued by 15 of the largest MAOs during June 1−7, 2019.”
Inappropriately denied Medicare Advantage prior authorizations are the evil twin of up-coding. But rather than boosting profits by improperly increasing Risk Adjustment scores, this practice retains profits by denying appropriate care.
Medicare Coverage Rules
MAOs must follow Medicare coverage rules, which specify what items and services are covered and under what circumstances. Because MAOs must provide beneficiaries with all basic benefits covered under original Medicare, they may not impose limitations—such as waiting periods or exclusions from coverage due to pre-existing conditions—that are not present in original Medicare.
A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.
Access to quality healthcare is a human right, and CMS wants to ensure that money is not getting in the way of that. Value-Based Care payment models are designed to align financial incentives with patient outcomes. On one side of the equation, CMS and the DOJ regularly audit (and prosecute) health plans and provider groups for up-coding or over-coding diagnoses that are not supported in the documentation – essentially, getting paid for providing needless care that does not benefit patients. In this report, OIG is looking at the other side of the coin: patient care that should have been provided, but was denied in appropriately.
Both are financial mechanisms to boost earnings or cut costs at the expense of patient care. And while we usually focus on the HCC coding and documentation side of the fence, denying care that should have been approved is potentially worse. Up-coding raise costs unnecessarily, but patients are still receiving care – although at times needlessly. By highlighting the problem of inappropriately denied care, OIG is actually uncovering a problem that is, in essence, refusing to provide appropriate and necessary care.
MAOs denied prior authorization and payment requests that met Medicare coverage rules by:
using MAO clinical criteria that are not contained in Medicare coverage rules;
requesting unnecessary documentation; and
making manual review errors and system errors.
By ratcheting up the clinical criteria beyond Medicare rules, MAOs that inappropriately deny coverage or payments are skimming the til at the expense of patient care.
By requiring unnecessary documentation beyond CMS guidelines, an MAO can appear to be taking documentation and accuracy very seriously, when in fact, they are actually just withholding care for profit.
What OIG Found
Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services (e.g., MRIs) and stays in post-acute facilities (e.g., inpatient rehabilitation facilities).
Prior authorization requests.
We found that among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules—in other words, these services likely would have been approved for these beneficiaries under original Medicare (also known as Medicare fee-for-service). We identified two common causes of these denials. First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. Although our review determined that the requests in these cases did meet Medicare coverage rules, CMS guidance is not sufficiently detailed to determine whether MAOs may deny authorization based on internal MAO clinical criteria that go beyond Medicare coverage rules.
Second, MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the beneficiary medical records already in the case file were sufficient to support the medical necessity of the services.
Again, increasing clinical documentation requirements beyond CMS’ requirements is not cool.
We found that among the payment requests that MAOs denied, 18 percent met Medicare coverage rules and MAO billing rules. Most of these payment denials in our sample were caused by human error during manual claims-processing reviews (e.g., overlooking a document) and system processing errors (e.g., the MAO’s system was not programmed or updated correctly). We also found that MAOs reversed some of the denied prior authorization and payment requests that met Medicare coverage rules and MAO billing rules. Often the reversals occurred when a beneficiary or provider appealed or disputed the denial, and in some cases MAOs identified their own errors.
What OIG Recommends
Our findings about the circumstances under which MAOs denied requests that met Medicare coverage rules and MAO billing rules provide an opportunity for improvement to ensure that Medicare Advantage beneficiaries have timely access to all necessary health care services, and that providers are paid appropriately.
Therefore, we recommend that CMS:
(1) issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews;
(2) update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types; and
(3) direct MAOs to take steps to identify and address vulnerabilities that can lead to manual review errors and system errors. CMS concurred with all three recommendations.
In effect, the OIG is recommending adding a category to the already rigorous audits associated with MAOs. RADV audits may in the near future also address inappropriately denied Medicare Advantage prior authorizations.
So the takeaway here is to aim for the Goldilocks of clinical documentation integrity: neither too lax nor too strict, but just right, in line with CMS guidelines.
As always, we have an app for that. HCC education that helps your team achieve that perfect zen-like balance of accurate diagnoses, properly documented and ready for any audits. We deliver just-in-time learning on HCC codes related to conditions specific to the upcoming patient visits. And your clinicians earn 25 hours of CME per year, while operations achieves the Goldilocks of documentation: not too hot, and not too cold.
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.
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.
As we look forward to the release of ACPLAN’s 2022 Alternative Payment Method report, let’s review data from their previous six annual reports. One clear takeaway is that Value-Based Care payments increasing year over year is a trend that shows no signs of stopping. Trend lines point to the inevitable rise of Full Risk, but slowly – as most of the year-over-year movement is coming from transitions from FFS linked to quality to full VBC models.
The APM Framework is the LAN’s landmark achievement, establishing a common vocabulary and pathway for measuring successful payment models. Originally published in 2016 and refreshed in 2017, the Framework classifies Alternative Payment Models (APMs) in four categories and eight subcategories, specifying decision rules to standardize classification efforts. It lays out core principles for designing APMs, which have influenced payers and purchasers, and forms the basis of the annual APM Measurement Effort. Private payers like Anthem use the Framework to set value-based payment goals, and at least 12 state Medicaid agencies use it to set value-based purchasing requirements in contracts with managed care organizations.
From the HCPLAN, Health Care Payment Learning & Action Network
HCPLAN Annual Reports show Increasing Value-Based Care Payments
Within the constructs of this framework, the LAN publishes a yearly report of dollars spent across the four categories, from Category 1(traditional Fee-For-Service or other legacy payments not linked to quality), Quality Category 2 (pay-for-performance or care coordination fees), and Categories 3 & 4 (VBC arrangements with shared savings, shared risk, bundled payment, population-based payments, integrated finance and delivery system payments).
Industry trending toward VBC, Risk, Value-Based Care Payments Increasing
By plugging in data from their annual reports, we can see that the market-share of the various payment models has been shifting toward categories 3 & 4, VBC arrangements with shared savings, shared risk, bundled payment, population-based payments, integrated finance, and delivery system payments.
The trends are clear and compelling: dollars spent in category 3 & 4 payment models are steadily rising, category 2 (pay-for-performance or care coordination) is declining, and Fee-For-Service is gradually shifting downward.
Since releasing their first report in 2016, HCPLAN has been tracking not just the dollars spent, but the trends over time. The below graphic shows one view of the data, as dollars spent increase across all payment models, but does not show the changing position of the various models.
CMS Innovation Center Goals Dictate Value-Based Care Payments Increasing
The CMS Innovation Center has stated that the goals of their strategic direction are that:
All Medicare fee-for-service beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030.
The vast majority of Medicaid beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030.
While the 2030 goal appears ambitious, the trend-lines are trending in that direction. Not only is Value-Based Care increasing as a total percentage of all payments, but specifically categories 3 & 4 are increasing against category 2. The movement is both away from Fee-For-Service and moving toward full risk models.
HCPLAN Annual Reports Demonstrate Increasing Value-Based Care Payments
Below, we have linked all the HCPLAN data from previous year’s studies, with links to their interactive reports. The data is clearly pointing to Value-Based Care payments increasing, year-over-year.
The overall change from 2019 to 2020 was very small, with Categories 3 & 4 gaining most ground from Category 2, and Category 1 (FFS) moving very little. It will be interesting to see how 2021 measures up.
Will Category 1 remain stalled at 39.3%, or will things continue shifting away from FFS? Will Categories 3 & 4 continue to take from Category 2, or will FFS give up a few of its dollars to VBC? We are grateful for the work of the LAN, and eager to see the next report. Optimistic, even!
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…..
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.