HCC Coding Audits

Medicare Advantage was created in 1997, and in 2007 the risk adjustment phase in was completed for the participating Medicare Managed Care Organizations (“MCO’s.”) The risk adjusted reimbursement model is based on chronic and cumulative conditions called “hierarchial condition categories (“HCC’s.”)

The historic model for physician reimbursement has been fee-for-service. Doctors get paid for the services they provide to their patients. The CPT codes and their individual relative values essentially drive reimbursement and the ICD-9 diagnostic codes support themedical necessity of those services under this structure. The Medicare Advantage HCC model turns this upside down. With 100% risk adjustment, the ICD-9 diagnostic codes do more than support medical necessity; they now drive CMS’s payments to MCO’s for their Medicare Advantage members.

There are more than 3,000 ICD-9 codes that can adjust risk, but only 70 HCC groups.  Diagnoses are classified into groups to include clinically related conditions with similar cost-of-care ramifications. About 80% of the diagnoses used in the Risk Adjustment Processing System (“RAPS”) originate from the physicians’ claim forms. The RAPS creates a Risk Adjustment Factor (“RAF”) that identify the individual patient’s status. All of this is highly influenced by the historic costs of caring for specific chronic diseases, and payments are based upon the most severe disease manifestation. Comorbidities can have a significant impact on the RAF and HCC determination, and consequently the MCO’s reimbursement.

MCO’s can look backward in the medical recods to correct incomplete coding. This involves reviewing the patients’ medical records to look for documentation that supports any of those 3,000+ previously unreported diagnoses (unreported because they may not have been the medical necessity for a reported service.)

The Coding Network can support your retrospective HCC chart audit program by providing your MCO with the skilled and experienced coders to quickly and cost-effectively reivew your triaged medical records. Importantly, we can provide on-site provider medical record documentation education to train them on thorough and accurate diagnostic coding and the need to see new members quickly to accurately establish their RAF’s. This avoids having to wait a year or longer for the retrospective audits to correct the RAF and underpayment.

Please call 888-CODE-MED to learn more about our HCC audit services.

Latest Blog Posts:

  • 20921548_s

Dermatology Physicians / Practice to Pay $1.9 Million to Settle Overbilling Medicare for E&M Services

April 21st, 2016|Comments Off on Dermatology Physicians / Practice to Pay $1.9 Million to Settle Overbilling Medicare for E&M Services

Abusers of the Medicare system can sometimes be intentional or not, but the stories that really get significant attention of the public are the ones that highlight healthcare personnel that intentionally over bill Medicare.

There are […]

  • Screen Shot 2016-02-22 at 8.59.06 AM

Calif State Medicaid Fraud Unit Recovers $795 Million in Judgements

February 22nd, 2016|Comments Off on Calif State Medicaid Fraud Unit Recovers $795 Million in Judgements

California State Medicaid Fraud Control Unit: 2015 Onsite Review (OEI-09-15-00070) http://go.usa.gov/cpgj5 Why We Did This Study

OIG oversees all State Medicaid Fraud Control Units (MFCUs or Units). As part of this oversight, OIG conducts […]

  • Effects of ICD-10 on Coding Production - Example from MGMA Community

Effects of ICD-10 on Coding Production – Example from MGMA Community

January 12th, 2016|Comments Off on Effects of ICD-10 on Coding Production – Example from MGMA Community

Now that ICD-10 has been rolled out, medical coding companies are feeling its effects. The Medical Group Management Association (MGMA) and its affiliates are having to recreate their processes in order to account for the […]

  • Screen Shot 2015-12-18 at 9.54.46 AM

$750,000 HIPAA SETTLEMENT CAUSES OCR TO UNDERSCORE NEED FOR ORGANIZATION WIDE RISK ANALYSIS

December 18th, 2015|Comments Off on $750,000 HIPAA SETTLEMENT CAUSES OCR TO UNDERSCORE NEED FOR ORGANIZATION WIDE RISK ANALYSIS

In a $750,000 HIPAA Settlement, the University of Washington Medicine (UWM) has agreed to settle charges that it potentially violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule by failing to implement […]