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HCC Challenges and How Providers Can Overcome Them

Many providers are feeling overwhelmed by the complicated and myriad changes that are occurring in the healthcare space as the industry works toward value based care goals. If your practice feels like you’re drowning in alphabet soup and there are significant obstacles to overcome in order to begin and get up to speed with HCC coding, here are some things to think about. It may be easier than you think, adding HCC capture to your practice is relatively straightforward to implement and has a very high return rate.

Pssst! You can also download our whitepaper on HCC Coding

CMS Goals and Health Risk Component

CMS has initiated programs to broaden the spectrum of population health management and achieve six major quality and strategy goals. These goals are the impetus for the drive to value based care:  

Goal 1: Make care safer by reducing harm caused in the delivery of care.
Goal 2: Strengthen person and family engagement as partners in their care.
Goal 3: Promote effective communication and coordination of care.
Goal 4: Promote effective prevention and treatment of chronic disease.
Goal 5: Work with communities to promote best practices of healthy living.
Goal 6: Make care affordable.

First, establish the health risk cycle and thoroughly document the level of care needed/received so the provider may properly show the cost of care for his/her patient population and represent that to the payer accordingly. One of the first steps includes a three part health risk assessment which directly relates to all six of the goals listed above.

  1. Assessment (AWV) - During the office visit, the provider will require the patient to complete tasks designed to assess health risk. For example, the patient is given a series of words to recall which assess their cognitive function. The patient is asked to walk across the room to determine fall risk, etc. After the initial risk is determined the patient moves through the cycle to health risk adjustment.

  2. Adjustment (HCC) - The clinical documentation reflects how severe the patient condition is and is measured by the HCC codes that are documented during the patient visits. Other alternative payment models (APMs) like like Medicare Advantage (MA) plans, Medicare Shared Savings Programs (MSSP),  Comprehensive Primary Care (CPC+), and select private plans  are using HCCs now to determine risk adjustment.

    And, you can bet that  more will follow soon.

  3. Management (CCM) -  This health risk management step applies to patients with chronic conditions who need a higher level management of care across specialities and facilities. Proper care management with engaged patients and informed providers is a huge part of working toward the CMS strategy and quality goals.  

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Identifying Conditions and Engaging Patients

One of the first challenges providers are facing is determining what the risk baseline is for their particular patient population. Patient engagement is the key to creating that baseline. If high risk patients are not following up on their care or scheduling the visits when they should, the provider cannot capture the patient visit in a qualified care encounter. The provider’s office needs to be proactive in scheduling patients and ensuring they are coming to their appointments. The reason for the visit may not be directly related to the chronic condition, but the chronic condition still needs to be documented in order to properly capture the patient risk through HCC.

Building a Foundation for Success

One of the most important foundational skills that will help providers in the long term is creating and maintaining accurate, specific and easily referenceable medical records. Take the opportunity now to diligently and consistently identify your patients’ health risk and create integrated workflows to manage chronic conditions. Build workflows, and optimize your EMR to help capture your patient population health risk. This improves the risk adjustment factor, which is the calculation that the select payers and alternative payment models base reimbursement on for the cost of care.

The Bottom Line

HCC challenges may seem difficult to conquer, but each step that is taken moves your practice forward in the value based care game. Work to improve capture scores, show the true cost of care for managing the population health among your unique patient demographic, and create integrated workflows to help with documentation and condition identification in the medical record. Starting now to overcome the challenges that HCC presents will be a positive investment in the future of your organization and for your patients.


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