Risk Adjustment

Provider Specialists: Targeted Strategies for Capturing HCC Codes

Most healthcare organizations focus their risk adjustment efforts on finding their members’ diagnoses through primary care physicians. The first point of contact for almost all patients, PCPs are vital resources in the risk adjustment process. But when a member’s PCP is unable to provide the correct chart with all the suspected diagnoses, where does the healthcare organization turn? In Medicare Advantage plans, medical specialists often step in and play an important role in treating patients.

Analyzing provider and HCC data shows that when PCPs don’t diagnose a condition that a member is suspected of having, organizations can target specific specialists to optimize their retrieval results. Healthcare organizations will increase their success rate when they know which specialists are diagnosing which HCC codes the most. The table below shows the results for five of the most common HCC codes.

Diabetes with and without chronic complications, corresponding to HCC codes 18 and 19, respectively, is a major condition that often isn’t found by the primary care physician during a patient’s regular checkup. Many PCPs will refer their patients to a specialist for treatment, or patients will initially seek out a specialist for conditions that they may not realize are symptoms of diabetes. While cardiologists and oncologist-hematologists may intuitively seem like the expected resource for diagnosing and treating diabetes, healthcare organizations may be more effective in capturing their population’s HCC codes if they reached out to their members’ foot and eye doctors.

Restricted blood flow, nerve damage, and cuts and blisters that won’t heal—all symptoms of diabetes— can cause great pain and damage to the feet in particular. The American Diabetic Association states that preventative care from podiatrists is vital in reducing foot ulcers or need for amputation among high-risk patients. Therefore, Medicare patients are recommended to visit a podiatrist at least once a year for a foot exam if they have diabetes, and even more regularly if their diabetes is significantly affecting their feet. Since foot pain is less likely to be a chronic condition, podiatrists are more likely to diagnose for HCC 19 than for HCC 18. Nearly a fifth of HCC 19 conditions are diagnosed by podiatrists, compared to around 14% of HCC 18 conditions. And even that is a significant portion of HCC codes.

Similarly, the ADA recommends to diabetes patients that they visit their eye doctor annually for a comprehensive eye exam. Conditions such as cataracts, glaucoma, or retinopathy are strongly associated with diabetes. These chronic complications that diabetes patients often experience explains why 20% of all HCC 18 diagnoses are captured from ophthalmologists. Comparatively, ophthalmologists capture 16% of all HCC 19 diagnoses, not the largest chunk but still the second most out of all specialists.

Kidney disease is a major risk for people with diabetes, and will often require specialized treatment, such as dialysis, that can only be administered by a nephrologist. Data shows that nephrologists make up the largest specialist group in finding diagnoses that associate with HCC18. The chronic nature of kidney disease explains why nephrologists are on top of list for HCC 18 but much lower on the list for HCC 19. Given the greater risk adjustment impact of chronic conditions compared to non-chronic conditions, healthcare organizations should take special notice of patients visiting nephrologists.

Data shows the efficacy of directing retrieval efforts of specific HCCs based on different types of specialty providers. Diabetes conditions may be concentrated in a handful of specialties, but knowing which ones to prioritize in retrieval initiatives can make potentially huge impacts on risk adjustment gains. This can become especially helpful when delving deeper into less common conditions that are more difficult to capture but have high value.








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