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HCC Coding Audit

11-02-17Darlene Almanza

Risk adjustment auditing and provider education is a required element in our gain-share methodology for Innovation Health.  The goal is to educate the providers on the link between the financial benchmark (expected cost of care) and value-based payments (gain-share).  This year Signature Partners quality team collaborated with the Inova Professional Billing Office to complete the auditing of its network providers. Our goal was to audit 90% or more of adult primary care providers with at least 50 or more active Innovation Health members attributed to the practice TIN at the end of the first quarter. The team reviewed 330 encounters for 110 providers for documentation of chronic conditions. Feedback was provided to the practices for the opportunities to improve Hierarchical Condition Category (HCC) coding as well as Evaluation and Management (E&M) coding accuracy and gaps in evidence-based care for patients with diabetes, heart failure, and COPD. Some of the opportunities identified in regards to HCC coding include:

  • Primary diagnosis not listed in the first position
  • Documented chronic conditions/diagnoses not reported
  • Use of ICD10 ending with “9” when progress note clearly specify the definitive diagnoses
  • Codes for patient’s noncompliance are not being utilized
  • Risk factors are not being coded; e.g. obesity and tobacco use

Signature Partners will continue to be a resource for HCC coding education for our providers.

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