Risk Adjustment

V23: How To Ensure Retrospective HCC Code Capture

When the new CMS-HCC Risk-Adjustment Model (V23) took effect in January 2019, it included 4 new HCC categories, 83 new HCC codes and more than 9,500 ICD-10 codes. Capturing the codes will be a challenge since they require special expertise on the part of the provider. When it comes to retrospective HCC code capture, it’s vital that plans have the right data and processes to ensure accurate reimbursement. Here are some strategies to consider.

Know the criteria for HCC code capture

To ensure effective retrospective HCC code capture, providers must learn more about the physiopathology of the conditions and how to better diagnose them. For CKD3 for example, providers can ask about a member’s symptoms or identify the underlying causes such as type-2 diabetes or hypertension during an annual wellness visit. For the new psychiatric HCCs, providers must have the DSM-5 criteria and know how to make a differential diagnosis. For example, more than 3 positive criteria indicates drug dependence while less than 3 positive criteria indicates drug abuse.

It’s also important that providers understand the different forms of support that are needed for medical record documentation for CMS’ validation. For CKD3 for example, providers may not have the GFR value to specify the stage, but if they are providing treatment for it, it is considered a form of support from a CMS perspective.

Utilize the provider query for HCC code capture

A provider query is an effective way to retrospectively capture HCC codes and it can be conducted in two ways. The first way to conduct a provider query is during a concurrent code review. After coders review the medical record, they can then identify conditions that lack support for accurate HCC capture, or missed HCC opportunities. The chart is then sent back with a query to the provider to get the additional documentation and close the HCC gap in a compliant way.

Another way to conduct a provider query is to identify the clinical evidence to support the opportunity and send it to the PCP. The PCP will then capture the HCC at the next appointment based on the clinical evidence that was sent and they have the option to agree or disagree with the evidence. If the condition was partially addressed during a previous visit, the provider can also amend the chart to accurately capture the HCC.

With our epiAnalyst solution, we help our clients identify HCC opportunities and close gaps quickly and more efficiently. To learn more, contact us today.


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