Precision and foresight are required in healthcare to not only accurately diagnose and treat current ailments, but to also anticipate the future health issues and needs of patients. Hierarchical Condition Categories (HCC) codes are vital tools in this regard. These codes allow you to categorize patient conditions with accuracy, as well as enable you to predict potential healthcare costs and resources.
HCC codes of recurring HCC diagnoses need to be recaptured (recoded) every twelve months so that the condition is not removed from the patient record by Medicare, which will happen if it is not recaptured.
In a time when healthcare is as much about proactive management as it is about treatment, it’s essential to understand the importance and use of HCC codes and how many HCC codes there are. The structure of these codes ensures that each patient gets care that matches their health status, bridging the gap between clinical insight and administrative efficiency.
There are currently eighty-six HCCs in the payment model, although the number of HCC categories will increase to 115 in 2024. Fully grasping the intricacies of HCC codes puts you at the forefront of patient-centered care by balancing the importance of diagnosis and efficient resource allocation.
The recapture rate refers to how many healthcare providers consistently and accurately document recurring HCC diagnoses every year. In essence, it’s a measure of how well providers ensure that ongoing diagnoses are re-documented as required by Medicare. The industry standard for this rate is typically 85%, meaning that providers should recapture at least 85% of recurrent HCC diagnoses annually.
While the two concepts are strongly related, there is an important distinction between HCC capture and recapture:
The core difference therefore comes down to the persistence of a diagnosis. A provider might “capture” a short-term diagnosis, but if the problem goes away within a year they will not “recapture” it.
Maintaining this consistency in recapture rates is deeply interwoven with the broader goals of healthcare and related financial matters. Both the risk scores of patients and the associated financial benchmarks for providers and facilities should ideally remain steady throughout the year. This stability is crucial, especially in value-based program settings.
This is because a consistent risk score is imperative for ensuring that the anticipated financial benchmarks, or the financial targets based on which payments are determined, remain consistent and predictable. A drop in the risk score, possibly because of failures in capturing recurring diagnoses, could lead to lower financial benchmarks.
This, in turn, could result in reduced financial allocations and reimbursements. Robust recapture rates are critical to the financial health of the organizations providing patient care.
In a value-based care model, where payments are intricately linked to the perceived risk and quality of care. Maintaining risk scores through consistent coding practices is pivotal for sustaining financial viability.
Risk adjustment is a complex process designed to account for differences in expected healthcare costs for different patients. Central to this process is the risk adjustment score, or Risk Adjustment Factor (RAF), a numeric representation of a patient’s anticipated healthcare needs and subsequent costs based on their overall health conditions and demographic factors. This score is crucial in ensuring that healthcare providers are not financially penalized for taking care of patients with more complex and costlier health needs.
The HCC system is critical in determining RAF scores. As a healthcare provider, every time you code a diagnosis corresponding to an HCC, it impacts the patient’s overall risk score. Consistent and accurate documentation of recurring HCC diagnoses, reflected in the HCC recapture rate, ensures that RAF scores remain current and genuinely represent the patient’s health status.
An optimal HCC recapture rate, typically targeted at around 85%, indicates that providers reliably capture most ongoing HCC diagnoses each year. Consistent documentation is key. Any lapses or inconsistencies in capturing these recurring HCCs can result in an understated risk score, which could, in turn, negatively affect your financial benchmarks.
Maintaining an accurate and consistent RAF score is crucial in a value-based reimbursement system, where payments are based on perceived risk and quality of care. Aiming for a high HCC recapture rate is not just a coding best practice, it is a vital strategy for ensuring accurate reimbursement and accurately representing the complexity of the patients you serve.
Inferscience offers cutting-edge software solutions for healthcare providers, enabling efficient analysis of patient data from external health records. Our comprehensive 360-degree data approach aggregates patient records from diverse healthcare providers, including clinics and labs.
To support robust HCC recapture rates, our system consistently flags recurring HCC diagnoses, aiding in accurate coding and maintaining risk adjustment scores. Whether you need data in specific formats or real-time HCC coding suggestions at the point of care, we’ve got you covered.
