HCC Diagnoses Sent to Payor?

In value-based care programs such as Accountable Care Organization (ACO), Primary Care First (PCF), or Direct Contracting Entity (DCE), the patient risk score plays a vital role in determining the payment levels or financial benchmark.

The first step in any HCC coding program is to verify the HCC diagnoses were sent and received by the payor. While the HCC diagnosis code may exist in the electronic health records (EHR) system, that does not mean the code was sent to the payor for processing. If not sent to the payor, then the HCC diagnosis is not included in the calculation of the risk score and financial benchmark.

An easy way to check all HCC diagnoses are being sent and received by the payor, is to compare your Medicare claims data for an individual patient to the diagnoses coded in your EHR. If codes are missing in the Medicare claims data, then you have a problem and need to further investigate your billing process.

The standard issue is the configuration of the billing system is set to only send a certain number or codes or the system isn't configured to pull the HCC diagnoses as a priority list.

Kris Gates, [email protected], 480.912.1209