Cracking the Code to Improve Patient Care and Reimbursements

August 5th, 2021 | Published Under HIE Participants by Bob Mook

CORHIO training program helps healthcare professionals and payers adapt to risk-adjustment payment models

With more Colorado healthcare providers and payers pivoting from a fee-for-service reimbursement approach to a value-based care (VBC) model, there’s an ongoing learning curve for all concerned.

In short, VBC is a healthcare delivery model in which providers are paid based on the health outcomes of their patients and the quality of services rendered. Under VBC contracts, providers share in financial risks with payers.

The model is predicated on helping payers to understand, forecast and plan for costs of patient populations -- knowing that higher-risk populations cost more and lower-risk patients cost less. However, if diagnoses and morbidities are not coded correctly by a medical office, there’s potential for lost reimbursements and worse patient outcomes.

Hierarchical Condition Category Coding
Because most healthcare professionals aren’t experts in coding, CORHIO’s Healthcare Quality Improvement team provides audits, training and feedback to help them properly report and analyze Hierarchical Condition Category (HCC) codes.

Used by Medicare’s Medicare Advantage and Primary Care First plans, HCC is the risk-adjustment model that most payers mimic. Simply put, HCC identifies patients with serious, acute or chronic conditions. It assigns a risk score based on patient demographics and medical history to inform reimbursement rates.

Jolene Reini, a Healthcare Quality Improvement Advisor at CORHIO, says that HCC and other risk-adjustment models are garnering interest as more healthcare providers begin to understand how this approach benefits patients’ health as well as the bottom line. Still, even the most astute healthcare professionals might struggle to keep up with the ever-changing codes without training and advice.

“Basically, providers need to know that codes should be documented at least once a year because Centers for Medicare & Medicaid Services resets those codes every year. Sometimes there’s a revaluation of the code, sometimes there are new codes that have been introduced,” Reini says.

One emphasis in CORHIO’s trainings is the importance of supporting documentation in a patient’s history.

“In the outpatient setting, you cannot code for a diagnosis until it is definitive,” Reini says. “You need to use a history code if a patient’s medical history is relevant to their care. You cannot pull diagnoses into a note from the problem without supporting documentation.”

Large Boulder health center utilizes HCC
As Director of Nursing for Boulder Medical Center, Melissa Johnson directs care management for an independent, multidisciplinary practice with over 80 primary care and specialty doctors. Boulder Medical Center completed a comprehensive HCC training with CORHIO earlier this year.

“There’s a huge push for HCC from a quality standpoint,” Johnson says. “The better the picture you have for the patient, the better care you could provide for them.”

Johnson credits Lauren Girard, CORHIO’s Healthcare Quality Improvement Director, with tailoring her trainings to reflect specific findings from an audit of Boulder Medical Center’s codes.

“CORHIO has been really helpful in explaining the purpose of HCC coding, why it’s important to their specialties, how they should be coding and what’s important specifically for them,” Johnson says.

Contact CORHIO’s Healthcare Quality Improvement team to learn more about training and other services for quality reporting and improved reimbursements.

Jolene Reini, CRC, Healthcare Quality Improvement Advisor for CORHIO, explains the basics in risk coding and how to identify common coding errors in this recorded webinar.