Outpatient CDI: The Intersection of HCCs

Original story posted on: October 25, 2021

Creating a compliant HCC chart review process.

EDITOR’S NOTE: Colleen Deighan will be conducting a Talk Ten Tuesdays Listener Survey on CDI today.

When healthcare organizations are considering, planning, or beginning efforts centered on documentation integrity in the outpatient setting, Hierarchical Condition Categories (HCCs) are the majority focus. With the shift of care from inpatient to outpatient and from fee-for-service to value-based payment models, a focus on risk adjustment and HCCs aligns well with this changing landscape. In risk adjustment payment models, demographics and diagnoses from claims data are used to measure an individual’s risk score or risk adjustment factor score, often referred to as RAF score. The RAF score is used to predict future spending. Whether your healthcare organization is large or small, outpatient CDI programs focused on improving clinical documentation in physician clinics and across the care continuum to support HCC diagnosis capture represent a vital component of risk adjustment. 

With HCCs, one workflow decision that needs careful consideration is the timing of the medical record review. What is the best option for the biggest return on investment, while ensuring compliance with coding guidelines and accurate claims submission? The record review process and its impact on patient care must also be taken into consideration. A HCC medical record review can be prospective, concurrent, or retrospective. Whichever the type, however, the intent of the review is to identify HCC conditions documented and coded in the prior year, but not the current year; conditions documented in the current year, but not coded or captured on a claim; conditions lacking documentation specificity that would impact the HCC; and clinical indicators of disease progression wherein documentation is needed to capture the acuity accurately with ICD-10-CM codes. Using technology or working with your managed care department to identify at-risk patients allows documentation integrity specialists to focus their review efforts on the right population of patients.

A prospective review is done prior to the patient’s scheduled encounter, typically three to five days prior to the visit. A concurrent review is done while the patient is in the office and documentation of the visit is being completed; this can be difficult to do, depending on the volume of encounters and the length of the visit in the physician clinic setting. A retrospective visit is done after the visit is completed, either before or after the claim has been submitted. 

All these options have their pros and cons. With a prospective visit review, provider queries can be sent and reviewed by the provider before the encounter begins. A retrospective visit review ensures that all the HCC conditions were documented appropriately, and captured with the ICD-10-CM diagnosis codes. Any conditions not meeting documentation requirements can be removed from the claim; however, retrospective queries can be difficult to manage. If the retrospective review is done after the claim has been submitted, the claim must be corrected, and the administrative burden of this process can be very costly. Understanding documentation practices in the physician clinic is a must when deciding the timing of the review. Be open to refining the review process as your outpatient CDI program matures.   

There have been several allegations and a settlement in recent months regarding Medicare Advantage plans and providers. On Aug. 30, the U.S. Department of Justice (DOJ) announced that Sutter Health and its affiliates agreed to pay $90 million to settle False Claims Act allegations that they violated the Act by “knowingly submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans.” Know and follow the coding and reporting guidelines; do not assign diagnosis codes without proper documentation. It’s really that simple.

Programming Note: Listen to Colleen Deighan report this story live today during Talk Ten Tuesdays, 10 Eastern.


Colleen Deighan, RHIA, CCS, CCDS-O

Colleen has more than 25 years of technical and managerial experience in health information management.  As a consultant, Colleen provides advisory services for ambulatory CDI, outpatient facility and professional coding for 3M.

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