By: Renee Subaran

The stakes are particularly high for physicians caring for patients enrolled in Medicare managed care plans. The changes currently taking place with respect to data collection, coding, and billing are some of the most significant transformations in the history of the Medicare Advantage (MA) industry. One of the best ways to combat these reductions is to focus on Hierarchical Condition Category (HCC) coding. Since 2004, Medicare has used the HCC model to calculate payments to providers and health plans, but the sad truth is that most MA plans and their aligned physicians continue to miss significant opportunities to serve their members and maximize their revenue potential because of poor performance in this area.

Billing systems such as Meditouch can help to improve scoring as the proper coding is suggested when a physician fills out the application.

Here are a couple tips to ensure you high scoring:

· Know how many diagnosis codes your claims system is capable of storing. Data is often lost merely because your system does not have a place to hold it. To ensure you are receiving accurate reimbursement, you must be able to capture and send all diagnosis codes from your claims and encounters.

· Find out if new patients already have assigned HCCs from their prior health plan. If so, be sure that you maintain those (if appropriate) moving forward. Doing so will assist with both continuity of care and comprehensive data collection.

· CMS expects member’s conditions to be documented and assessed each year. For that reason it is important to monitor each member’s HCCs for consistency in reporting. Pay particular attention to patients whose HCCs may be dropping as this could be an indication of gaps in care or in failing to accurately document services that were provided. Remember, CMS reimburses because resources were expended, as evidenced by documentation in the medical record, not because a member has a chronic condition.

· If you are using an electronic data interchange (EDI) vendor, have a discussion with them to make certain you receive reports on rejected items. Also ask them to verify the maximum number of diagnosis codes they capture and transmit to your health plans. You may be able to locate diagnosis codes, otherwise lost, that will positively affect your revenue.

A physician’s reimbursement factor can be more or less than 100% of Medicare allowable, depending on the yearly total of the point values for the RAF diagnoses that have been recorded. They have to be recorded on a face to face physician/PA/NP encounter. They have to be documented in the particular way that CMS requires. Three things are necessary: the Diagnosis (with documentation to support it, including copies of labs and x-ray reports that meet criteria for the diagnosis), the Status ("New," "Stable," "Worse," or "Improved" HAS to be written with each diagnosis, either in a separate list of diagnoses or in the Comments for the diagnosis), and the Plan for each Diagnosis. All in all, the best way to improve scoring is to stay informed and use third parties for billing.

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