Codebusters manages the entire cycle of HCC (hierarchical condition category) code assignment and documentation training, providing Medicare Advantage plans the information they need to adequately quantify risk and plan for the future.  Our team of experienced professionals identifies risk areas, calculates financial impact, and engages in thorough cost analysis to justify business intelligence strategies.  The process of data retrieval, analysis, and communicating documentation and coding methods to physicians, requires careful planning and experience.  Managed care organizations find that they can reduce their operating expenses by turning to Codebusters for the management and execution of the systems necessary to fully capture the ICD-9 codes that determine HCC assignment.

There are four main elements that comprise the HCC coding cycle as outlined below.  Each demands its own logistical considerations and skill set to perform.  We achieve cost savings throughout each part of the cycle by understanding every aspect of the necessary inputs and carefully planning and coordinating their implementation.

Engagement Planning

We help our clients quantify of the value of diagnostic, procedural, and quality indications, then calculate the resource costs necessary to collect the data.  The records selected for review are a function of the benefit they return to an organization and the costs of extraction or validation.  Understanding the marginal contribution the data set elements provides assurance return on investment is optimized.  The process starts with defining the client’s information needs based on stated objectives.  We then begin asking the right questions of the data; for example, in what patient and provider populations do coding omissions or errors materially affect reimbursement and also leave the organization vulnerable to government compliance violations.  

Offense must be played to maximize reimbursement based on the risk of the patient population.  However, defense has become critical since CMS began random Risk Adjustment Data Validation (RADV) audits.  Risk Adjustment Factors (RAFs) that determine payment from CMS must be supported by documentation in the medical record.

Data Retrieval

Records may be in an electronic format, scanned images, partially scanned, or paper.  The target documents need to be identified and the permission protocols established (onsite versus offsite audit). The records can either be uploaded to a secure environment where coders and other analysts can easily navigate to relevant sections or coders can access the record at the provider’s office.

The provider’s internal practices and office layout, as well as the number of records to be audited at a given site, will dictate the most expeditious and cost effective solution.  If records are in a paper format the costs, timing, and limitations of the individual physician practice dictate whether we will scan the records or have then transmitted via secure fax.  Our onsite conduct ensures minimum disruption to the provider’s workflow.

Auditing

Coders determine the correctness or absence of diagnostic codes.  The documentation which justifies code selection is evaluated to clarify if it meets compliance standards.  The documentation needs support the diagnosis codes which are changed or added in order to stand up to an audit and create a repeatable system for doctors to follow.  Utilization management professionals examine whether prescribed treatment pathways were followed and help identify successful protocols.  Detailed information about a patient’s condition and response to treatment overtime illuminates best practice treatment protocols and risk modeling methods to quantify future revenues and expenses.

Error Prevention Strategies

Our auditors understand physician production environments.  We can help providers comply with MA plan documentation requirements without significant impact to their productivity.  Clinicians need concise, clinically relevant feedback that they can easily implement and remember.  Coding guidelines can be referenced for inclusion into the compliance program

• Individualized training based on audit findings for physicians and their staff, onsite or remote
• Identification and solutions to systemic barriers to proper documentation
• Practice management consulting to ensure consistent/dependable communication flow between provider and payer
• Medical group documentation training from concepts to specifics
• Supplement Compliance Program guidelines to reflect audit findings and industry best practices
• Pre-bill monitoring and shortened audit intervals enhance reliance

Primary Care Physicians (PCP) serve a critical role in determining a patient treatment path and ultimate use of services (utilization management).  Most of a patient’s experience and interface with the health plan is via their PCP.  Likewise, much a PCP’s interaction with the health plan occurs via the auditing and training process.  Plans who form a collaborative relationship with PCPs will experience positive patient feedback.  Thus, patient will be more likely to stay in a given MA plan.