HCCs and Risk Adjustment Are Aligned for Value-Based Care

An emphasis on Risk Adjustment solutions and HCCs correlates well with the shifting environment in the healthcare sector as care is in transition from inpatient to outpatient and from fee-for-service to value-based reimbursements.

 

Demographics and diagnoses from claims data are used in Risk Adjustment (RA) reimbursements to calculate a patient's risk score or Risk Adjustment Factor score, often known as RAF score. The RAF score is said to anticipate future care expenditures. Outpatient CDI initiatives concentrating on enhancing patient records in general practitioner facilities and around the healthcare ecosystem to enhance HCC diagnosis detection are a critical component of Risk Adjustment, regardless of how big or small the healthcare institution is.

 

The Junction of HCCs:

 

When it comes to HCCs, one procedural decision that must be carefully evaluated is the timeline for reviewing the medical chart. The record review mechanism, as well as its influence on care delivery, should be considered. HCC Coding for health data is evaluated prospectively, concurrently, or retrospectively. Regardless of the kind, the purpose of the review is to discover HCC coding recorded in the previous year but not in the current year.

Medical conditions recorded in the current year but not represented on a claim; conditions with poor record-keeping specificity that would influence the HCC Coding; and clinical findings of illness development where data is necessary to record the severity using ICD-10-CM codes appropriately. By implementing a new HCC Coding Solution in the care facility to identify at-risk persons, data security specialists can concentrate their review efforts on targeted patient groups.

 

Prospective Review:

 

A prospective review is carried out three to five days before the patient's scheduled session.

 

Concurrent Review:

 

A concurrent review is performed while the patient is in the clinic, and the visit is recorded; this can be challenging to attain in the physician facility owing to the large number of interactions and the duration of the visit.

 

Retrospective Review:

 

A retrospective visit is made after the completion of the appointment, either before or after the claim has been lodged.

 

All of these alternatives have advantages and disadvantages. Provider inquiries can be sent and evaluated before the appointment begins via a prospective visit review.

 

A retrospective visit review confirms that all HCC Coding is appropriately documented and coded using ICD-10-CM diagnostic codes. Any conditions that do not fulfill documentation standards can be deleted from the claim.

 

If the retrospective review is performed after the claim has been filed, the claim must be rectified.