HCC Coding to Improve Patient Outcomes and Increase Revenue

April 26, 2019

Under fee-for-service models, oncologists’ clinical documentation centered around in-office encounters, with the objectives of maximizing collections while minimizing burdensome paperwork. Comorbidities were most commonly documented as part of the patient intake process for emergency visits. Under value-based reimbursement models, like the OCM, oncologists are now responsible for treating each cancer patient holistically. This includes managing patient outcomes across all conditions and care settings.

As one multi-specialty group practice discovered, documentation gap mitigation would be paramount to success under the program. The practice, serving OCM patients at more than 40 office locations throughout the Midwest, had demonstrated success in addressing avoidable ED visits and hospitalizations by increasing patient engagement via care management teams. Surprisingly, while reduced resource use lowered total cost of care among their patient populations, most practices were still exceeding the CMS Target Price. With the help of Integra Connect, they uncovered that insufficient comorbidity documentation was driving down the CMS Target Price and negatively impacting the practice’s perceived performance. In short, because the practice had not shifted their documentation approach, comorbidities were not being coded and billed. With more accurate and complete coding of comorbidities, Integra Connect found that the practice could raise their CMS Target Price by as much as $4,800 per documented comorbidity – a 50 percent increase.

To facilitate ongoing documentation improvement, the Integra Connect Analytics team developed a personalized dashboard to help the practice proactively identify and address comorbidity documentation gaps, leveraging the latest complete episode practice data. The dashboard enabled the practice to:

  • Identify patients for whom a higher number of comorbidities has been documented historically.
  • Notify clinicians and request that the missing patient information be added to encounter notes.
  • Revise claims as necessary with up-to-date coding information, ensuring optimal CMS Target Prices.

Moreover, by highlighting patients with a history of comorbidities, Integra Connect empowered the practices’ care teams to proactively manage these higher-risk patients, referring them to the appropriate specialists who could help them manage their comorbid condition, which resulted in incremental reductions in total costs of care. In the case of the practices’ cancer populations with cardiac conditions, the practice realized a 19 percent reduction in total cost of care due to increased referrals of cardiac patients to a cardiologist.