Risk Adjustment Coding

Address your challenges with QBS Services’ HCC Risk Adjustment Coding Services.

As the healthcare industry increasingly shifts toward value-based reimbursement, accurately capturing patient conditions through risk adjustment coding has become crucial for estimating future healthcare outcomes and costs. While various factors, including demographic characteristics and health status, contribute to calculating the risk of a patient population, the primary consideration is the patient’s diagnosis codes. The resulting risk score indicates how much a provider should allocate for patient care over the year. Inaccurate data capture can lead to incorrect diagnosis coding, which may adversely affect healthcare services, outcomes, and reimbursement.

As one of the leading risk adjustment coding companies, QBS Services provides comprehensive risk adjustment documentation and coding services by promoting accurate clinical documentation and supporting it with precise diagnosis coding. Our risk adjustment coding solutions are designed to deliver a complete view of a patient’s health, enabling better care plans, improved outcomes, reduced costs, and optimal reimbursement.

HCC Medical Coding

The Hierarchical Condition Category (HCC) Coding Model is an advanced risk-adjustment framework designed to more accurately estimate future healthcare costs for patients. This model assigns a risk score, known as the Risk Adjustment Factor (RAF), to each eligible beneficiary based on their health conditions and demographic factors such as age, gender, and institutional status. It groups clinically related diagnosis codes based on resource usage, meaning that a higher risk score indicates higher anticipated costs.

It’s essential to understand that while diagnosis codes for billing are used to identify the reason for a visit or treatment, all diagnosis codes for current conditions must be captured for risk adjustment purposes, regardless of current treatment, and must be supported by documentation. This is where we come in as an HCC coding company! Our HCC risk adjustment coders ensure that documentation is thorough, assign appropriate diagnosis codes that meet the TAMPER (treatment, assessment, monitor/medicate, plan, evaluate, or referral) or MEAT (monitor, evaluate, assess, or treat) criteria, and guarantee that health plans, Accountable Care Organizations (ACOs), and providers receive accurate compensation while delivering the highest quality of care.

Risk Adjustment Reviews

Our certified risk adjustment coders possess the experience and expertise to conduct risk-adjustment reviews prospectively (before a patient is seen), concurrently (before a claim is billed), and retrospectively (after a claim is billed).

Prospective Risk Adjustment

Reviewers play a crucial role in evaluating all available patient information, including previously documented HCC codes, prescription medications, hospital records, lab results, and physician notes. Often certified risk coders, they analyze these diagnostic details to ensure accurate coding, assess the risk level associated with each patient’s health, and provide the provider with a list of potential HCC diagnosis codes to consider during the encounter. This assessment not only helps providers prepare treatment plans for identified conditions in upcoming appointments but also assists payers in predicting costs for the following year using data from a base year. Accurate data is essential for properly calculating premiums and reimbursements.

Concurrent Risk Adjustment

In the concurrent coding review process, our certified risk adjustment coders examine medical records and HCC codes in real time before claims are submitted to payers. This ensures that claims are accurate, complete, and compliant with regulations prior to submission. Concurrent coding reviews help reduce errors by catching them before claims are sent, and they also provide predictions for future costs based on current year information. Additionally, this approach allows providers to receive payment for services rendered more quickly, as it minimizes time spent resolving issues related to incorrect or incomplete claims.

Retrospective Risk Adjustments

Retrospective coding review is a vital component of the claims process for healthcare providers, conducted after care has been provided and claims submitted to the payer. This review ensures that accurate and appropriate HCC documentation and codes were used during claim submissions. Retrospective coding reviews are critical for identifying any HCC codes that may not have been reported despite existing documentation, as well as spotting instances where HCC codes were reported without sufficient documentation. This process highlights coding gaps and areas for improvement in practice operations and billing procedures, ultimately reducing costs and enhancing accuracy in the future.

The QB Advantage

Our team has extensive experience in assisting organizations with risk adjustment reviews. We recognize the critical role the HCC framework plays in risk adjustment coding, both from a reimbursement and a health management perspective. Through our tailored workflows and strategies, we help organizations enhance their clinical documentation and coding accuracy, fostering business growth. Still need convincing? Here are some additional reasons that set QBS Services apart in risk adjustment coding.