Preparing for a RADV audit? Follow these six steps.

In the ever-evolving landscape of healthcare compliance, the Risk Adjustment Data Validation (RADV) audit stands out as a critical process that demands meticulous preparation. Being proactive and implementing a strategic approach can not only streamline the audit process but also ensure your organization’s success. Let’s explore the six steps organizations should remember to successfully prepare for a RADV audit.

1) Understand RADV requirements

The first step in preparing for a RADV audit is to have a comprehensive understanding of the requirements. Familiarize yourself with the RADV guidelines, protocols, and any recent updates. This includes staying informed about the CMS (Centers for Medicare & Medicaid Services) regulations and documentation requirements. The more intimately you know the rules, the better positioned your organization will be to meet and exceed compliance standards.

2) Conduct internal audits

Performing internal audits is a proactive measure to identify and address potential issues before the RADV audit. Regularly review your coding practices, documentation accuracy, and submission processes. This internal assessment will not only help in identifying any gaps but will also serve as a valuable opportunity to rectify discrepancies and enhance overall coding accuracy.

3) Ensure accurate documentation

Accurate and detailed documentation is the backbone of a successful RADV audit. Providers must ensure that medical records accurately reflect the patient’s health status, including all relevant diagnoses. Implement a robust documentation improvement program to address any shortcomings and educate staff on the importance of thorough and precise documentation.

4) Invest in training and education

Education is key to compliance. Regularly train your coding and documentation teams to stay abreast of the latest coding guidelines and RADV audit requirements. Investing in ongoing education not only ensures that your team is well-informed but also helps in creating a culture of compliance within your organization. In addition to traditional HCC coding education methods, new engaging tools are now available that significantly enhance knowledge retention compared to traditional approaches. 

One such tool, the DoctusTech mobile app, stands out as a premier provider of HCC coding education in this field. Clinicians can utilize the app to enhance their knowledge and stay current on HCC coding. Schedule a demonstration to discover how DoctusTech supports healthcare providers in training their clinicians.

5) Implement technology solutions

Leverage technology to streamline your RADV audit preparation. Implement advanced coding and documentation tools that can identify potential discrepancies, errors, or missing information. Automated solutions can significantly reduce the risk of oversights and enhance the overall efficiency of your coding and documentation processes.

DoctusTech is a groundbreaking tech solution that transforms HCC code capture. This platform simplifies the process for clinicians to precisely record HCC codes within their EMR for each patient. With DoctusTech HCC 360, EMR workflows are streamlined by consolidating external data sources and presenting information to clinicians in real time as they document progress notes. Integration with major EMRs is seamless. To discover more about this innovative product, schedule a demo today.

6) Establish a communication plan:

Effective communication is vital during the RADV audit preparation. Establish a clear communication plan within your organization to ensure that all relevant stakeholders are aware of their roles and responsibilities. Foster open lines of communication between coding teams, documentation specialists, and leadership. This collaborative approach will help in addressing challenges promptly and ensuring a cohesive effort toward RADV audit success.

In conclusion, considering how to prepare for a RADV audit requires a proactive, strategic approach. By understanding the requirements, conducting internal audits, ensuring accurate documentation, investing in training, leveraging technology, and establishing effective communication, your organization can navigate the complexities of the audit process with confidence. Stay vigilant, stay compliant, and pave the way for a successful RADV audit.

7 Strategies to improve HCC coding and risk adjustment accuracy

Healthcare is a dynamic and complex industry, constantly evolving to provide the best possible care to patients. In this ever-changing landscape, accurate Hierarchical Condition Category (HCC) coding and risk adjustment in the value-based care healthcare model play a crucial role in ensuring quality care, managing patient populations, and optimizing revenue. Here are 7 strategies to improve HCC coding and risk adjustment accuracy in your VBC organization.

1. Streamlined clinical workflows

Streamlined clinical workflows reduce administrative burdens and free up healthcare providers to focus on patient care. Efficient workflows can also aid in capturing HCC codes more effectively. Organizations should evaluate and optimize their workflows to ensure that providers have the time and resources necessary for accurate coding.

2. Regular coding audits and feedback

Regular coding audits are essential for identifying errors and areas for improvement. They help organizations ensure compliance with coding guidelines and enhance accuracy. Feedback from audits can guide coders and providers in refining their coding practices. These audits can be conducted regularly, and the findings should be used constructively to improve the coding process.

3. Data analysis

Data analysis is an invaluable tool in risk adjustment. By analyzing patient data, organizations can identify gaps in coding and areas for improvement. Data-driven insights can help pinpoint under-documented conditions, ensuring that all relevant HCCs are captured. This analysis also helps organizations gain a deeper understanding of their patient populations.

4. Comprehensive provider education

Healthcare providers are at the frontline of patient care, and their understanding of the importance of accurate HCC coding is paramount. Comprehensive education programs ensure that healthcare professionals are well-informed about the significance of documenting chronic conditions accurately. By equipping providers with the knowledge and tools they need, organizations can improve coding at the source. 

One of the leading HCC coding education providers in this space is DoctusTech. It’s an app that clinicians can use to learn and stay updated about HCC coding. Book a demo to earn how DoctusTech helps healthcare providers train clinicians.

5. Proper documentation training

Training healthcare professionals in the nuances of proper documentation is vital. These training programs help providers understand the specific details required for accurate HCC coding. Coding specialists or educators can play a significant role in delivering this training, ensuring that providers are well-equipped to document patient conditions comprehensively.

6. Advanced EHR and documentation tools

Electronic Health Records (EHRs) have become integral to healthcare documentation. Implementing advanced documentation tools within EHR systems can prompt providers to capture relevant HCCs during patient encounters. These tools can offer real-time suggestions and guidelines, aiding providers in accurate coding.

One of the revolutionary tech solutions for improving HCC code capture is DoctusTech. It makes it easy for clinicians to accurately document HCC codes for every patient within their own EMR. DoctusTech HCC 360 streamlines EMR workflows by combining all external data sources and presenting information to clinicians as they write their progress notes. It can integrate with all major EMRs with minimal hassle. Book a demo here to learn more about this product.

7. Collaboration and communication

Effective communication and collaboration between coders, providers, and administrative staff are vital for HCC coding accuracy. Open channels of communication allow providers to seek clarification or guidance on coding, and coders to provide feedback or request additional information when necessary. This collaborative approach fosters a culture of accuracy and ensures that everyone is working together towards the common goal of improved coding.

In conclusion, accurate HCC coding and risk adjustment are essential for healthcare organizations to deliver quality care while optimizing revenue. These seven strategies – comprehensive provider education, advanced EHR tools, streamlined workflows, regular coding audits, proper documentation training, data analysis, and collaboration – collectively form a robust framework for enhancing coding accuracy. By implementing these strategies, healthcare organizations can meet the challenges of the evolving healthcare landscape while improving patient care and financial outcomes.

As the healthcare industry continues to evolve, following these 7 strategies to improve HCC coding accuracy is an essential step. By investing in accurate HCC coding and risk adjustment, healthcare organizations can ensure that they are well-prepared to provide the best care to their patients while achieving financial sustainability in an increasingly complex healthcare ecosystem.

To improve your HCC coding accuracy with the DoctusTech app.

What is the CMS HCC Risk Adjustment Model?

The CMS, or Centers for Medicare & Medicaid Services, developed the HCC Risk Adjustment Model to determine Medicare Advantage (MA) plan payments, based on the expected healthcare costs of plan enrolees. HCC stands for Hierarchical Condition Categories, which are groups of medical conditions that share similar expected costs of treatment.

Since its inception in 2004, the CMS HCC Risk Adjustment Model assigns each MA enrolee a risk score based on their demographic information – such as age and gender – their medical conditions, and the severity of those conditions. The risk score is calculated by first assigning HCCs to each enrolee based on their medical diagnoses, then applying a weight to each HCC based on the expected cost of treatment. These weights are then added up to determine the enrolees’ overall risk score.

The CMS HCC Risk Adjustment Model is designed to account for differences in the health status and expected costs of care among MA enrolees, and to ensure that MA plans are adequately compensated for the medical needs of their enrolees. The risk adjustment methodology is used to adjust payments made to MA plans based on the enrolee’s risk score, with higher risk scores resulting in higher payments to the MA plan.

The CMS HCC Risk Adjustment Model is updated annually to reflect changes in the prevalence and costs of medical conditions, as well as changes in the coding and classification systems used to identify medical diagnoses.

What is a RAF score? 

The Risk Adjustment Factor (RAF) score is a measure used to adjust the payment for healthcare services based on the health status and expected medical costs of the patient. The RAF score is typically used in the context of Medicare Advantage (MA) plans, which are a type of health insurance offered by private companies that contract with Medicare to provide Medicare benefits to eligible individuals.

The RAF score is calculated using a formula that takes into account the patient’s demographic information, such as age and gender, as well as their medical conditions and the severity of those conditions. The formula assigns a weight to each medical condition based on its expected cost of treatment. The weights are then added up to determine the patient’s overall RAF score.

So a patient has a RAF of 1.5 may have a 0.6 from demographics, a 0.3 for diabetes, and 0.6 from COPD. 

The RAF score is used to adjust the payment made by Medicare to the MA plan for each patient. Patients with higher RAF scores are considered more expensive to treat, and the MA plan will receive a higher payment to cover the expected costs of care. This helps to ensure that MA plans are adequately compensated for the medical needs of their patients, and that patients with more complex health conditions receive appropriate care.

How do HCCs relate to it?

Each year, Medicare calculates an amount of money that will be paid per member per month (PMPM).  This same base rate is paid out for every patient, regardless of what services were done.  This base rate is then multiplied by the patient’s RAF score so that more money is payed out to take care of patients with a high RAF (sicker patients) than those with a low RAF (healthier patients).  

If a CMS patient has a high RAF, they he/she is expected to get extensive medical care, clinicians who enrol these are reimbursed more than those who have low RAFs. The additional reimbursement amounts for patients who qualify will not be paid to organizations that do not properly or completely document HCC codes as incorrectly documented codes do not add to the RAF score.

To know more about HCC coding and how to improve it, you can refer to our blog on ‘How to improve HCC coding and avoid risks.’

Risk Adjustment Coding – Challenges And How To Get It Right

Risk Adjustment Coding

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.

[Book a Demo]

Conclusion

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.

4 HCC Coding Challenges All Clinicians Face

4 KEY HCC Coding Challenges Clinicians Face

As the U.S healthcare system transitions towards value-based payment models, independent clinicians and physician groups continue to face HCC coding challenges that not only impact their bottom-line, but patient care as well. On top of all this, the pandemic has added a significant burden to the already stretched clinician workload.

 

Here are 4 key HCC coding challenges clinicians are facing now, and how they can overcome them.

 

  1. Physician training for HCC coding – Physicians are already working tirelessly to provide excellent care to their patients. Asking them to learn HCC coding through brute-force via zoom calls, classroom seminars and email blasts is a bridge too far. On the other hand, the focus on value-based care has made it imperative for physicians to know and understand HCC coding so that they can accurately document patient records. So clinicians know they need to know, they just don’t have an effective and engaging mechanism for efficient and effective learning.

 

  1. Revenue impact due to incorrect coding – Accurate HCC coding is necessary for accurate reimbursements and patient care, and inaccurate coding can directly impact the bottom line. That is why it is imperative that clinicians and staff be well trained in HCC coding. And the complexities don’t stop there. HCC codes not only impact RAF scores, they also interact directly with patient care, and a fair level of decision support is required , as HCC codes are not intuitive.

 

  1. Poor HCC integration with EMR systems – When HCC coding does not integrate with the EMR, it creates a complex struggle for clinicians and physician groups. This not only leads to unintentional errors, but makes workflows more difficult and adds to the burden of an already heavy workload. It is critical to put a system in place that teaches clinicians to accurately document HCC codes on every patient, and integrates within the EMR.

 

  1. Lack of trained HCC coding professionals – Staffing shortfalls not only plague small practices, but larger physician groups are short-staffed as well. A lack of well-trained staff may be related to revenue or rising salaries, which sometimes small practices are unable to sustain. And when larger hospitals acquire smaller practices, a shortage of trained staff is often just one side-effect. Training clinicians and non-clinical staff on HCC coding is vital.

 

Transitioning to a value-based care model will never be seamless until these challenges are solved. How? With our unique suite of HCC education and EMR integration tools, enabling physicians to learn HCC coding and integrate an AI-powered HCC coding system into their existing EMR platforms to drive efficiency and accuracy.

 

To learn how our HCC coding app lets physicians train for HCC coding click here.

 

To understand how our EMR integrated platform works, click here.

What is HCC Coding: Risk Adjustment Models in Value-Based Care

What is HCC Coding?

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.

What is HCC Coding and Risk Adjustment?


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.”

What is HCC Coding and Risk Adjustment?


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.

Conclusion

 

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.

 

— DoctusTech Team

 

Sources
https://www.inovalon.com/inovalon-insights-blog/hcc-coding-improve-risk-adjustment/
https://www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/an-introduction-to-hierarchical-condition-categories-hcc
https://www.3mhisinsideangle.com/blog-post/hcc-coding-whats-the-big-deal/
https://www.aafp.org/fpm/2016/0900/p24.html