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.
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 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…..
If you’re a physician group engaging in value-based care arrangements: coding and documentation accuracy should be your top priorities.
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.
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 Doctus 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:
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.
Doctus 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.