Three Coding Mistakes That Kill Revenue for Primary Care Practices and Payers
In medical billing, accuracy is just one aspect of getting claims approved. The job also requires ensuring full and fair reimbursement while staying compliant with CMS rules and avoiding coding gaps.
Incomplete coding is a silent revenue killer for primary care practices and payers. Inadequate or incorrect documentation of diagnoses or Hierarchical Chronic Condition (HCC) codes handcuffs risk estimates and almost assuredly means a mismatch in available service funds to meet affected members’ total cost of care.
What are the challenges to accurate HCC and diagnosis coding? We’ve identified three curable causes that, given attention, can help ensure future revenue meets the expected cost of sicker members.
1. Undercoding Out of Habit
Including the appropriate codes for member conditions in combination with documentation of each procedure and service is essential to managing a patient’s medical history and optimizing revenue. Still, many primary care physicians code conservatively, habitually forgoing CMS risk score calculation guidance to avoid audits.
However, undercoding as a defensive strategy or simple negligence leads to:
- Improperly paid claims
- Skewed data for payment calculation/risk-adjusted factor scoring
- The risk of audit
Misrepresentation of care and members’ conditions in a provider’s claims causes payers to miscalculate future medical costs, creates inaccurate risk-adjustment scores, and flags physicians as outliers, subject to payer audits.
2. Misclassifying & Dropping Chronic Condition Codes
Distinguishing between chronic and acute conditions allows for a patient’s medical history to reflect their long-term health status accurately. Inarticulate documentation can lead to misclassification of chronic conditions and affect member care, misalign service funding, and shortchange provider reimbursement.
Similarly, the recent mandatory transition to HCC v28 requires a proactive approach from payers and providers to achieve coding accuracy and data analysis. To thrive in this new model, documentation and data submission are paramount.
While this transition to a new HCC model is inherently positive and should result in higher reimbursement rates, it also brings a change in documentation expectations and data analysis that payers and providers will have to adapt to benefit from the new model and not lose revenue.
3. Allowing EHR Templates to Drive Coding
Allowing only Electronic Health Record templates to drive coding can result in lost revenue because of missed HCC codes. While EHR templates can be used as a resource in collecting member history, they don’t successfully account for the full range of information needed for accurate chronic condition coding.
Similar to undercoding, following EHR templates can expose providers to the risk of audit, result in revenue loss from denied claims, and cause inaccurate risk assessment scores. To solve for this, FRG created AccuReports.
AccuReports ingests and standardizes unstructured data from EHR notes for thorough member profiles that can be reviewed retroactively or mined to suggest relevant diagnoses and secondary conditions for upcoming CMS risk adjustment data submission deadlines.
Strengthen Your Revenue Strategy with RAMP
FRG’s RAMP reports and dashboards highlight opportunities to capture revenue from historically documented chronic conditions and ensure revenue alignment with the cost of care. RAMP can help payers and providers see where codes and documentation are missing to manage risk with distinct treatment of CMS model V28 by:
- Modeling the impact of diagnosis capture
- Generating timely reports on dropped chronic condition codes and members not seen
- Estimating recapture opportunity for previously accepted chronic conditions
- Computing changes in Medicare risk adjustment and CMS capitated payments
To learn more about FRG and how RAMP can set your organization on a path to achieving smarter billing, accurate risk-adjusted factor scoring, and, most importantly, financial health, contact us today.